SHS-COMM HOSP LEAD QUALITY IMPROVEMENT SPEC

General Purpose of Job:

Provides expertise in the area of Quality Improvement as it relates to practice, operations analysis, education and research. Promotes quality through utilization of the Performance Improvement (PI) Plan, Medical Staff Bylaws, external criteria (accreditation and regulatory standards) and policies and procedures of the health system. Major areas of focus include consultation (PI principles), collection, analysis and reporting of data and the facilitation of teams and projects as assigned.

Essential Duties:

This job description is intended to cover the minimum essential duties assigned on a regular basis. Team Members may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position.

• Produces severity-adjusted reports, with analysis, as applicable to quality issues. Utilizes system databases (e.g. Premier, EPIC, Quantros).
• Facilitates organizational compliance with external agency accreditation standards (e.g. the Joint Commission, Healthcare Facilities Accreditation Program).
• Collaborates with clinical and service line leadership and colleagues in identifying quality of care improvement opportunities.
• Analyzes and displays data using common PI tools (e.g. run charts, histograms). Maintains trended reports and summaries of key findings of Quality activities.
• Maintains knowledge of current trends and developments in Quality as it relates to regulatory and accreditation requirements.
• Participates in health system committees, task forces, and teams working to improve clinical quality and patient safety. The roles of the Quality Improvement Specialist includes leading, facilitating, consulting, and teaching, as well as acting as a liaison between the PI department, leadership, and team members.
• Designs, teaches, and evaluates Quality educational programs. Provides orientation and education of new physicians, managers, and caregivers.
• Develops Quality initiatives and indicators that identify opportunities for continuous improvement. Incorporates new developments in theory and standards of practice.
• Assumes leadership role on key organizational redesign activities in regards to quality, accreditation or regulatory projects.
• Develops business plans or process maps to achieve necessary outcomes.
• Provides clinical data as needed to fulfil OPPE and FPPE profiles on physicians.