Quality Improvement Specialist

Summary

Under the direct supervision of the Director of Quality Improvement, the Quality Improvement Specialist performs multiple clerical and analytical functions that impact regulatory compliance. With a focus on detail and accuracy, the QI Specialist will assist with data collection, documentation, tracking, communication, abstracting and support in all areas of the CMMC Quality Department. This includes providing specific registrar support for the Trauma/Stroke program and assisting with Patient Advocacy.

General Job Duties and Responsibilities

• Works cooperatively with all employees to carry out the goals and objectives of Connally Memorial Medical Center, according to the established policies and procedures and current initiatives.
• Accurately collects and collates data from a variety of sources such as clinical data from the EMR and other sources as needed for Quality Incentive Programs and other quality measures.
• Assists in gathering and recording data into excel or other designated formats for reporting to regulatory agencies and quality incentive programs.
• Works closely with on-site performance improvement teams to design, implement, and monitor quality improvement initiatives.
• Assists with completion of continuous improvement initiatives and projects
• Supports communication with all employees on quality issues.
• Performs other duties and assumes other responsibilities as apparent and/or as assigned by Director of Quality Improvement. Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice.
• Performs other duties as assigned.

Trauma/Stroke Registrar Duties and Responsibilities

• Performs Trauma and Stroke patient chart abstraction.
• Enters data and maintains Trauma and Stroke registry databases.
• Ensures that data are submitted in a timely manner to the Texas Department of Epidemiology State Trauma Registry.
• Assists the Trauma/Stroke Coordinator in the development of statistical reports and with performance improvement activities.
• Assists the Trauma/Stroke Coordinator in the collection and analysis of facility and regional data to identify and/or establish injury prevention and public education initiatives.
• Reports audit results and data to the Trauma/Stroke RN Coordinator who provides oversight.

Patient Advocate Duties and Responsibilities

• Provides clerical support for the Patient Advocacy process.
• Maintains the Patient Grievance/Complaint log.
• Assists with follow-up letters and documentation.

Education, Certificates, Licenses, Registrations

• High school diploma or equivalent.
• American Heart CPR.

Trauma Certifications & Education

• Basic Trauma Registry course required within 18 months of hire.
• AAAM Abbreviated Injury Scaling (AIS) course required within 18 months of hire.
• Data management course TETAF required within 6 months of hire.
• Certified Specialist in Trauma Registry (CSTR) desired but optional.
• Certified Abbreviated Scaling Specialist (CAISS) desired but optional.

Stroke Education and Competency Check-off

Provided by the Trauma/Stroke RN Coordinator.

Patient Advocate Education and Competency Check-off

Provided by the Director of Quality Improvement.

Experience

Hospital clerical experience preferred.

Patient care experience preferred (Patient Care Tech, Nurses Aide).

Knowledge, Skills, Abilities

• Customer Service and Team oriented.
• Demonstrated computer proficiency with MS Office products and the Electronic Medical Record.
• Ability to learn reporting requirements quickly and apply logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
• Strong written and verbal presentation skills.
• Excellent communication and interpersonal skills.
• Knowledge of medical terminology
• Ability to learn and understand metrics (creating, utilizing, analyzing and validating them)
• Ability to work well with others and to assist the public and other staff members cooperatively and courteously.
• Ability to convey information effectively.
• Efficient managing of own time and respectful of the time of others.
• Complies with all organizational policies.