Major Responsibilities:

• Provides consultation, facilitation and data support to performance improvement teams in order to improve quality, customer service, efficiency, and patient safety.
  • 1)Assists departments to develop indicators, trend data and maintain dashboards to monitor performance improvement initiatives.
  • 2)Provides guidance and support to team leaders and members to ensure an interdisciplinary, collaborative approach to performance improvement.
  • 3)Provides just-in-time training regarding CQI philosophy, PDSA, tools and methods.
  • 4)Leads and facilitates performance improvement teams.
  • 5)Provides support to teams including literature searches, data collection, statistical data analysis and display, and benchmarking.
  • 6)Assists in the development, implementation and evaluation of action plans to improve quality and reduce costs.
  • 7)Develops and provides interpretive performance improvement reports to highlight variations in clinical and non-clinical processes and outcomes for committees and leadership.
  • 8)Promotes patient safety by reporting issues through established channels and participating as requested in safety initiatives.
  • 9)Leads and facilitates teams to improve customer service.
  • 10)Serves as an internal consultant to clinical and managerial personnel with interpretation and evaluation of data.
• Performs performance improvement activities.
  • 1)Designs and implements clinical studies to identify variation in medical management in order to improve patient care and outcomes.
  • 2)Conducts case review and data collection.
  • 3)Provides graphic representation and statistical analysis of data.
  • 4)Prepares and submits performance improvement reports to medical staff and administrative committees.
• Facilitates performance improvement through active participation in the Medical Staff committees, Functional Committees and Organizational Department/Divisional Committees, as assigned.
  • 1)Insures that the required interdisciplinary and hospital-wide performance improvement activities are reported and acted upon.
  • 2)Disseminates comparative data to identify opportunities to reduce variation, improve outcomes and integrate best demonstrated practices.
  • 3)Designs and implements clinical studies to identify variation in practice resulting in improvements in patient care.
  • 4)Assists in writing interpretive reports and visual displays (i.e., control charts, run charts, bar charts, etc) highlighting variations in clinical processes, outcomes and improvement opportunities.
• Supports clinical information systems and preparation of clinical data reports for internal and external customers.
  • 1)Utilizes data from external databases for benchmarking as appropriate.
  • 2)Utilizes websites, i.e. Qnet Exchange, Accrediting Organization Quality Check, Hospital Compare, for monitoring and accessing publicly reported data.
  • 3)Develops and maintains clinical process and outcome dashboards of key initiative data for internal reporting.
  • 4)Ensures reports are accurately prepared and submitted in a timely manner.
• Participates in ongoing monitoring and improvement activities to promote ongoing regulatory compliance and ISO 9001.
  • 1)Promote ongoing survey readiness.
  • 2)Conducts Accrediting Organization Tracer mock surveys to monitor compliance with standards.
  • 3)Assures that departments under areas of responsibility are in compliance with regulatory agency requirements.
  • 4)Maintains current knowledge of regulatory requirements.
• Supports the Accrediting Organization, Hospital Quality Alliance (HQA) and other external initiatives specifically related to Core Measure requirements.
  • 1)Performs intensive chart reviews to abstract data required for monthly submission to public reporting efforts through CMS/Medicare and the Accrediting Organization.
  • 2)Understands and is able to apply knowledge of extensive technical instructions (i.e., Core Measure descriptions and data guidelines) specific to Sepsis.
  • 3)Uses a variety of computer applications to obtain patient and clinical information and to enter data, i.e. electronic medical record, MIDAS and the Internet.
  • 4)Monitors workflow to ensure that strict deadlines for data submission are met.
  • 5)Communicates often on complex technical issues, with a variety of clinical and administrative hospital personnel, including physicians and hospital leaders. Works closely with the Health Information Management department.
  • 6)Obtains additional information by participating in the Advocate Abstractor’s Forum and using resources such as teleconferences and the Quality Net Exchange Web Site.
  • 7)Works with hospital-wide contacts to enhance the quality of documentation required to appropriately reflect the high quality of care provided in the reported categories.
• Support physician and advanced practice clinician peer review efforts.
  • 1)Attenda mandatory educational requirements for the position.
  • 2)Participates in educational offerings to remain current with practice.

Licensure:

• Nurse, Registered (RN) OR Pharmacist, Registered OR Nurse, Advanced Practice (APN)

Education/Experience Required:

• Bachelor’s degree in nursing or related field. 3-5 years experience in an acute care health care environment; Knowledge of CQI theory and statistics; Knowledge of Accrediting Organization, CMS, IDPH & OSHA Standards
• 3-5 year's clinical experience preferred , Critical Care, Med-surge areas preferred, RN or Performance Improvement experience preferred

Knowledge, Skills & Abilities Required:

• Excellent communication and presentation skills; Excellent organization and prioritization skills; Ability to facilitate diverse groups/teams and understand/utilize knowledge of group dynamics; Computer literate in word processing, spreadsheets, graphic/data display and databases; Knowledge in meaningful data collection; Ability to analyze, interpret and display data; Basic knowledge of Midas quality management software
• Current IL Registered Nurse license; Registered Pharmacist, Registered Advanced Practice Nurse, Registered Physical Therapist, or Registered Physician Assistant
• Self-driven to work with inpatient leaders to do process improvement.
• Be able to critically think through problems and come up with creative solutions. Need to be organized and able to stick to deadlines.
• Ability to manage difficult situations when reviewing adverse outcomes.
Comfortable presenting in front of a large audience.

Physicals Requirements and Working Conditions:

• Resiliency and flexibility to deal with a changing environment. Ability to work under stressful conditions and in difficult situations. Innovative, self-motivated, detail-oriented. Ability to travel to off-site departments and Advocate Health Care facilities. Ability to work extensively on a personal computer.

Additional information:

• There is occasionally some cross coverage between sites as the departments are small.
• Will be required to participate in regulatory surveys including talking and presenting to surveyors.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.