Job Facility: UM Rehabilitation & Orthopaedic Institute
Employment Type: Not Indicated
What You Will Do:
I. General Summary
Under general supervision, coordinates departmental quality improvement activities to ensure consistency with organization policies, procedures and philosophy, and to maintain and improve the quality of care given to the patient. Develops, implements, and documents activities relating to the Quality Assurance Program. Collects, and analyzes data, conducts presentations, provides consultation, and staffs hospital-wide committees.
II. Principal Responsibilities and Tasks
The following statements are intended to describe the general nature and level of work being performed by the person assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.
1. Plans, organizes, and directs departmental quality improvement activities. Conducts departmental studies of identified problem areas in accordance with the Quality and Performance Improvement Plan.
Provides staff support to quality management committees by assembling data for review, transcribing minutes and assembling packets/handouts. Handles correspondence to/from committees by writing letters/memos to the appropriate person, department or committee informing them of the recommendation or actions to be taken. Receives correspondence from departments or committees and shares information with the Committee/department quality management physician.
Reviews data related to clinical care, in conjunction with the quality management committee, to determine committee agenda and identify areas requiring further information.
Prepares reports as required for medical staff, quality management committees and quality task forces to identify trends or patterns that present an opportunity to improve the quality of patient care provided.
Shares trends, patterns or issues identified during concurrent reviews, providing explanation and details regarding monthly quality assurance reports, and/or obtains medical records or additional information to be discussed.
Facilitates the clinical review and problem-solving processes through the use of quality improvement methodology and tools.
Coordinates special quality improvement projects and studies. Identifies resources needed, persons to be involved and the logistics of accomplishing the project. Participates in State and Federal Quality projects to obtain comparative data on quality indicators, to use in assessing how well the institution is doing in relation to others and compliance with The Joint Commission standards.
2. Analyzes and assesses the important aspects of care (such as appropriateness of diagnosis, blood transfusions, indication for surgery, clinical pertinence of medical record documentation, complications, anesthesia care, infections, utilization issues, etc.) for specific patient populations which represent important clinical issues and reflect the strategic clinical direction of the organization. Identifies areas for improvement.
Works with the healthcare team to determine the quality of care provided to support compliance with The Joint Commission standard of multidisciplinary approach to quality improvement
Identifies opportunities for improvement in the care provided.
Collects data for use during RFP/managed care contract negotiations.
3. Collects data for physician reappointment and Ongoing Professional Performance Evaluation. Develops close working relationship with medical staff office for improved information sharing and completion/ distribution of OPPE forms.
4. Develops strategies and action plans to correct the improvement areas. Responsible for ensuring that the goals are met based off of the action plans.
5. Facilitates multidisciplinary teams to achieve improved quality care.
6. Collects quality and risk management data on an ongoing basis such as unplanned readmissions, deaths, unplanned returns to the operating room, Maryland Hospital Association Quality Indicator Project Indicators, Clinical Quality Indicators for Board Report, occurrence screens, blood transfusion record completeness.
Measures and assesses data using pre-determined, medical staff approved criteria to identify cases requiring peer review, identify causes for indicator rate outliers and to document trends or patterns that identify opportunities for improvement in the quality of care provided.
Provides feedback to multidisciplinary teams regarding patient outcomes and processes of care.
7. Develops effective working relationships Risk Managers, Case Managers, and Department managers to assure cooperation and data sharing which results in improved patient care.
8. Provides consultation to ancillary support and clinical departments within the Medical System to establish quality indicators, analyze quality and utilization data, identify trends/patterns and formulate plans for resolving issues/problems.
9. Staffs organization-wide quality improvement committees and participates on process management teams.
What You Need to Be Successful:
Education & Experience
Bachelor’s degree in Nursing, or an equivalent combination of education and experience, is required.
Current licensure as a Registered Nurse in the State of Maryland is required.