Job Summary:

Responsible for the development, support and maintenance of data programs, data analytics and visualization models and dashboards utilized to support the Quality objectives of the organization. Analytical models may include, but are not limited to, Medical Staff Credentialing/Privileging, Clinical Quality Metrics, Clinical Quality Review & Peer Review Metrics, Provider Performance Metrics, Patient Experience, Quality of Care, Value-based Care, Financials, Hospital-wide Quality Measures & Metrics.

Develop and maintain an advanced understanding of the various data tables and how they interact with each other. Understand the flow of data from user input and job completion. Apply advanced knowledge of data concepts. Proactively audit and update data tables to ensure data integrity and quality prior to end user distribution. Training end user/customer on use of applications and business analytic tools to enable them to pull data needed on a regular basis.

· In collaboration with the Quality Director, evaluate the quality needs of the facility and develop analytical solutions. Participate in detailed requirement development and testing.

· Must appropriately triage projects and workload – prioritizing higher level leadership needs/initiatives and responsibilities assigned by the Quality Director.

• Assist Department Managers and Supervisors to improve processes and assist in development of action plans based on the data gathered. Proactively analyze quality data to discover opportunities for improvement; and directly notify, and actively work with, Managers and Supervisors on improving quality throughout the hospital.

• Monitor usage of analytical tools and perform activities to enhance meaningfulness and usability. Work towards minimizing manual data gathering.

• Proactively analyze data to discover opportunities for quality improvement, and work with quality teams to develop action plans for improvement.

• Provide expertise to facilitate the development of new models, and transfer of knowledge.

• Develop and implement system training programs to share knowledge to train staff. Serve as the primary contact for system-related user questions. Actively participate in educating staff on how to gather data and conduct meaningful analysis.

• Utilizing the tools and resources available, oversee dashboard and visualization design process within project related initiatives. Assist departments in making dashboard and visualization decisions and maintain written versions of all models built.

• Interact with users to gain an understanding of the data and visuals needed to analyze and support decisions.

• Working with IT and end-users, ensure that dashboards and visualizations are secure within the network and accessible only to authorized users.

• Analyze the source data modifying the data types, as necessary. Use excel, CSV files, etc. to generate adhoc reports. Perform incremental extracts, as needed. Ensure that dashboards and

visualizations incorporate appropriate features (i.e. trends, comparisons, axis, definitions, etc. as applicable) to facilitate complete and accurate analysis.

• Control changes to the analytical models created. Monitor adherence to standards of data security.

• Consistently observe confidentiality and security procedures. Report potentially unsafe conditions to appropriate personnel.

( 30%) Other Responsibilities

• Under the oversight of the VP of Quality, and under the direct supervision of the Director of Quality, the Healthcare Data Analyst identifies, obtains, enters, maintains and manages data from multiple sources regarding clinical quality processes and outcomes. Completes required surveys and reports as they relate to quality metrics, core measures, DNV, facility and other data/information, meeting required deadlines for each. Facilitates analysis and understanding of organizational performance improvement against quality goals and measures, ensuring data accuracy, currency, reliability and security. Provides Director of Quality with state, federal and other reports and results based upon Hospital data so that this feedback can be utilized for further process improvement.

• Responsible for maintaining the facilities system-wide Quality program – to include data collection, data validation, data uploads, and report creation including quality dashboards, logs and trackers. Coordinates and manages reporting of data and other functions related to requirements for publicly reported data (i.e. CMS, Leapfrog, Press Ganey, HANYS, etc.). Assists with preparation for and facilitation of surveys, audits and corrective actions for regulatory & accrediting agencies (DNV, CMS, NYSDOH, NYPORTS, etc.). Facilitates any audit activities including pulling and reviewing charts, formatting as required, and submission via file transfer protocols. Manages project flow to facilitate prioritization of quality improvement activities. Assists in the facilitation and accomplishment of Brooks-TLC Hospital quality goals through participation in quality initiatives such as EQIC, Press Ganey, CMS, Core Measures, and measurement of provider/departmental performance and departmental quality/performance improvement goals. Assist with development, data aggregation, and monitoring of provider reports and processes, including peer reviews.

• Serves on quality and performance improvement teams, committees and task forces as assigned – taking initiative to identify opportunities for process innovation and improvement; and, as assigned, assists in the efforts to organize, plan, implement and evaluate improvement efforts in identified processes; as well as other related quality goals and projects, as initiated and assigned. Leads teams, committees and task forces, as assigned, formulating presentations and actually performing presentations to groups, committee, etc.

• Establishes, develops and maintains continuous data collection systems and processes for quality and patient safety including defining data requirements, data collection procedures, database development and administration, assuring data accuracy, integrity and security. Delivers reports characterized by timeliness, thoroughness, accuracy and reliability with strong attention to presentation format and style.

• Accesses and utilizes various software programs including, but not limited to, WORD, Excel, Meditech, Premier Quality Advisor, PowerPoint, etc. to develop systems for tracking and maintenance of departmental and hospital-wide statistics (graphs, spreadsheets, reports, etc.). Accesses websites pertinent to quality (i.e. CDC, CMS, PGFusion, Quality Performer, ARRA tool, etc.) Continuously collects data related to core measures, quality metrics, preparing reports on a routine and as needed basis.

• Demonstrates knowledge of documentation opportunities, policies and procedures, statistics used for measurement and utilizes this information to assess trends and to prepare reports for senior management. Prepares monthly, quarterly and yearly data reports, power point presentations, etc. for the VP Quality, QPPC and the Board of Directors, with summary and succinct explanatory

information for ease of all meeting participants’ understanding.

• Works closely with Information Technology to ensure that all electronic data requirements are met. This includes but is not limited to eCQMs, Hybrid Measures, NYSDOH Sepsis Data, Promoting Interoperability data, etc. Validates data from the electronic reports generated by IT to ensure that all data points are present and that results accurately reflect the care provided. Provides feedback to Nursing, Pharmacy, Lab and other departments on process and documentation issues that are identified during data validation. Submits all required electronic measures in a timely manner.

• Assists with the onboarding and training of Clinical data abstractors, serving as a resource and providing feedback on case results, as well as facilitating process improvement opportunities based on abstraction results, as assigned.

• Serves on teams and committees, as assigned, charged with continuous process improvement in quality, service and patient safety. Assists in the development of project plans with clearly defined deliverables, methodologies, measures, timeframes, resources and costs, and leads multidisciplinary and institutionally integrated teams to achieve on-time deliverables that meet or exceed project outcome expectations. Follows up with teams to be able to secure, coordinate and deliver a high- quality product whenever the timeline is nearing or when a project has failed to initially meet the outcome expectations, in order to always meet expected outcomes.

• Assists, as assigned, with multidisciplinary and institutionally integrated teams focused on quality/process improvement through defining measures and data requirements, aggregating data and providing data reports that measure team progress toward achieving defined outcomes.

• Ensures essential communication is composed, produced, organized and disseminated for specific recipients, including managing electronic mail, preparation of communication and reports, correspondence to internal and external recipients, preparation of meeting agendas, information packets, minutes and responding to telephonic, electronic and hard copy communication, preparation of meeting agendas, demonstrating professional and courteous communication skills and a high degree of accuracy and attention to detail at all times.

• Other duties as assigned by the Director of Quality or the VP of Quality.

1. ( 20 %) Quality Improvement & Service Excellence: Responsible for participating in ongoing performance improvement activities, including, but not limited to: departmental performance improvement activities/initiatives and meeting change with a positive and supportive manner. Works to promote cooperative staff effort to provide and maintain high quality service to patients, physicians, and other hospital personnel to assure quality patient care. Courteously responds to inquiries from same. Demonstrates understanding of behaviors consistent with the Hospital Mission, Vision, Goals and Values. Recognizes the importance of customer satisfaction. Develops appropriate behaviors and attitudes regarding exceeding both internal and external customer expectations.

2. ( 5%) Compliance Regulatory Responsibility, Safety and Environment of Care: Responsible for complying with regulatory requirements and supporting organizational goals including, but not limited to: Ensuring compliance with relevant DNV, NYSDOH, federal and other regulatory requirements that pertain to department activities and actively supports the quality improvement philosophy, mission, goals and objectives of our organization. Respects and protects confidentiality of all patients and employees. Responsible for ensuring a safe work environment, including, but not limited to: reporting unsafe conditions/equipment to Supervisor; review and understands applicable SDS sheets and information; promote a safe work environment for employees, patients & visitors; possess knowledge and capability to respond to all hospital drills; report circumstances in which potential harm to patients & or employees may exist.

3. ( 5%) Continuing Education: Maintains professional affiliations and enhances professional growth and development by keeping abreast of the latest developments in appropriate area(s) of expertise through seminars, workshops, conferences, continuing education, etc. Participates with all departmental and facility wide mandatory and assigned education and training goals.

Education:

Required: BA/BS in Data, Business, Healthcare, Healthcare Services Administration, Information Systems, or similar

Preferred: Masters Degree in Data, Business, Healthcare, Healthcare Services Administration, Information systems, or similar

Preferred: Masters

Licensure/Certification Registration Requirements:

Required:

Preferred: Certified Professional in Healthcare Quality (CPHQ) within 18 months of employment.

Required Experience:

Required: 3 Years of experience: Data analytic and visualization tools to develop, maintain, or support the decision support needs within and/or across several departments.

Clinical data abstraction. Demonstrating strong data collection, presentation and data management skills. Healthcare licensure, accreditation and regulatory standards. Leading successful Quality Improvement Initiatives.

Data analysis specific to healthcare quality, clinical performance, and patient safety services.

Preferred: 5 years of experience: Data analytic and visualization tools to develop, maintain, or support the decision support needs within and/or across several departments.

Job Type: Full-time

Pay: $59,600.00 - $71,600.00 per year

Work setting:

• In-person

Experience:

• HEDIS: 1 year (Preferred)

License/Certification:

• Epic Certification (Preferred)

Ability to Commute:

• Dunkirk, NY 14048 (Required)

Ability to Relocate:

• Dunkirk, NY 14048: Relocate before starting work (Required)

Work Location: In person