Summary:
Is the primary staff support for medical staff and allied health professional ongoing professional practice evaluation and focused professional practice evaluation (OPPE/FPPE). Identifies opportunities for improvement, designs monitoring activities, evaluates clinical outcomes, and implements measurable plans for improvement. Collaborates with the Director to establish and maintain the annual quality activity calendar. The Coordinator is also responsible for the investigating and researching episodes that require intensive review, root cause analysis or peer review for the medical staff.
Position Responsibilities:

Is the primary staff support for medical staff and allied health professional for focused professional practice evaluation and in collaboration with the Senior Data Analyst for ongoing professional practice evaluation. (FPPE/OPPE). 

Reviews selected clinical outcome indicator data/reports for potential performance improvement review. (FPPE/OPPE). Identifies trends in core measure and other regulatory data.

Prepares / reviews charts with medical staff department chair, and Performance Improvement chair.

Populates and maintains performance dashboards for medical staff departments. Ensures that dashboards remain up to date with changing Quality and Safety requirements.

• Standardize and coordinate the case review process to ensure reliability
• Refine relevant physician measures for all performance dimensions or general competencies
• Ensure that peer review data is systematically collected and analyzed
• Prioritize use of resources for measuring physician performance.

Evaluates and analyzes medical records concurrently and/or retrospectively for determined quality indicators and report requests. 

Manages and trends data collection for an assigned hospital / facility.

Performs data entry of regulatory or other required information into appropriate databases. Evaluate, manage, and correct error reports within specified timeframes.

The Outcome Analyst is the primary source to verify diagnoses in the medical record for proper DRG coding. When symptoms in the medical record require further documentation, the Analyst queries the physician for a specific diagnosis for more accurate DRG coding.

Coordinates performance improvement activities according to the Virtua Quality Plan. Implements PI activities according to the DMAIC cycle, educating and coaching staff, managers and physicians in its use. Monitors and facilitates action plans for PI initiatives and the Medical Staff Dashboards. Demonstrates skills for leading and facilitating teams. Participates in local and system performance improvement teams (Six-Sigma, Kaizen, etc.) Assists the hospital team in with preparation, coordination and response to accreditation and regulatory agency visits or surveys. Keeps the Manager informed of all important quality issues under investigation and all committee or work group processes which may impact others in the organization.

Participates in patient safety initiatives, working in collaboration with department leaders to operationalize the Virtua Patient Safety program to identify risk, support reduction of errors and other factors that may contribute to unintended adverse patient outcomes.

Ensures compliance with Virtua Risk Management Program for local facility, including review and filing of incident reports, Safe Medical Device Act, reporting of Sentinel events, reportable events to the NJ DOH, etc. Investigates, reviews medical records and develops the timeline in preparation for root cause analysis meetings for sentinel, critical and reportable events. Also assists with record review for Patient Relations Manager/designee.

Position Qualifications Required / Experience Required:

Minimum of two years in quality management, health information management, case management, utilization review or other healthcare related field.

Must demonstrate the ability to accurately use a computer and standard office software such as Microsoft Excel, Word, Access and Power Point.

Must demonstrate effective verbal, written and presentation skills.

Must be able to establish and maintain an effective rapport with staff, physicians, managers and administrators.

Ability to coordinate multiple tasks and flexibility to balance changing priorities.

Required Education:

RN

Bachelor’s degree preferred.Training/Certifications/Licensure:
CPHQ or equivalent preferred