JOB SUMMARY: Provides clinical data analysis and direction related to clinical data abstraction in support of the Quality Improvement functions related to peer/medical staff review and clinical quality improvement activities.
Complies with the standards and guidelines promulgated by accrediting and regulatory agencies.
Exhibits a high level of initiative, accuracy, diplomacy, and self-direction; must be able to prioritize workload.
Identifies and pursues training opportunities (internal and external) within specialty and shares information freely with other staff members. Pursues program of self development, through various mechanisms.
Preceptors staff and new employees as assigned.
Promotes positive department and organizational problem resolution, promotes teamwork, cohesiveness and time management among self and other staff members.
Works efficiently with many projects underway simultaneously.
2.Analyzing / Assessing Current Performance
Continuously evaluates and monitors all aspects of clinical information management and communication to recommend modifications in approach.
Coordinates and provides data and reports in a manner understandable to the requesting audience.
Determines when drill-down of data will present useful information to identify areas for potential performance improvement opportunities.
Develops a conceptual understanding of all relevant databases and specific data being reported.
Keeps manager and appropriate department members informed of potential problems relative to database programs and of potential problems relative to Clinical Outcomes.
Maintains awareness of patient satisfaction survey reporting.
Analyzes cost and quality factors, utilizing a scientific approach, related to patient outcomes and makes recommendations to medical staff, nurse managers, service line managers and multi-disciplinary groups for change in practice to facilitate quality improvement and cost reduction environment.
Determines external benchmarks to identify best practices.
Effectively communicates information required for clinical decision making in order to facilitate medical staff resolution of utilization, complication, variation, and appropriate care issues and outcomes.
Identifies and tracks significant outcomes, performance data and compares current practice to research based literature.
Reviews and reports outcome and quality information to Administration, Medical Staff, management, staff and Board of Directors.
Works with Medical Staff Sections to present data and develop care protocols when applicable.
Monitors the effects and outcomes of pathways and the effects of outcomes of Clinical Effectiveness Plans..
Monitors, trends and reports patient outcomes to evaluate clinical and financial effectiveness
Monitors, trends and reports patient outcomes to evaluate clinical and financial effectiveness with specific expertise in focused service lines (e.g., Cardiovascular Services)
Communicates with Information Technology regarding system back-up, installation of upgrades and downloads.
Develops outcome monitors and determines source of data to provide information to Medical Staff and Board of Directors.
Participates in the development, implementation and revision of Clinical Effectiveness plans or high volume DRGs.
Develops, implements, and monitors clinical effectiveness plans and initiatives to improve patient and financial outcomes.
Accurately creates and maintains files, tables/graphs and edit layouts to facilitate accurate data reports.
4.Improving (and sustaining) Performance
Assists members of department and other key individuals and departments in promoting clinical outcome goals.
Assists with corrective action plans to respond to deficiencies identified and documented by review and accrediting agencies.
Trains and supervises other personnel in data entry and data support of appropriate information system applications.
Assesses overall performance of the facility to identify areas for improvement.
Assists in identifying resources needed to drive improvement throughout the organization and Medical Staff.
Collaborates with physicians and other personnel on patient care quality and satisfaction issues.
Communicates outcome measurements and quality indicator results throughout the organization.
Facilitates and supports quality improvement and disease management teams and projects
Identifies clinical information needs at the system level and coordinates findings with Strategic Planning.
Maintains knowledge in clinical practice, institution documentation, and quality indicators to make appropriate clinically-based judgment in data extraction process.
Partners with Clinical Effectiveness and other areas as appropriate (case management, education, etc.) to implement outcome goals.
Serves as a resource for physicians and organization staff in understanding criteria for quality initiatives.
Assists in maintaining a Clinical Effectiveness and Medical Management Plan and Performance Improvement Plan.
Coordinates performance improvement for clinical and support departments including the collection and analysis of quality data.
5.Monitoring (measuring) Performance through Data Collection
Independently assures data accuracy and assignment completion.
Maintains reports and distributes to the appropriate committees and individuals in a timely manner.
Responsible for documentation related to performance improvement activities including the PI quarterly report, JCAHO Core Measures data and generating trending reports for quality information.
Identifies and reports physician practice patterns and resource utilization on a routine basis to physicians, Medical Affairs, Administration, and others as appropriate.
Generates reports from systems and presents to various audiences.
Interacts positively with medical staff and other technical/clinical staff to ascertain completeness' and accuracy of data submitted into relevant databases.
Performs necessary database entry and analysis.
Remains current on data collection, data entry and reports.
Accurately creates reports and maintains documentation for future reference.
Assists in maintaining the outcome measurement system to report data to JCAHO to meet ORYX requirements.
Maintains current systems documentation.
Maintains database security system(s) to ensure confidentiality of all data.
Manipulates data to provide ad hoc and other unique reports and responds to requests for information from other departments as well as appropriate outside agencies.
Accurately collects clinical and demographic data for inclusion in JCAHO-related and cardiovascular databases, from physicians, clinical staff, medical record review and other source documents. Knowledgeable and remain current on criteria for data collection as set forth by hospital policy, database vendors, and professional organizations.
Evaluates and monitors all aspects of the management and communication of clinical (quality and satisfaction) information in order to recommend modifications in approach.
Submits reports in a timely manner to meet JCAHO Core Measures requirements.
Assists in preparing Harvest for analysis for professional alliances such as STS and ACC.
Accurately maintains extraction documents, patient log and filing systems, to assure accurate and complete documentation of patients entered into databases.
Assists with Medical Staff quality activities by collecting data on generic quality indicators.
Conducts chart review and identifies improvement opportunities related to peer review, mortality review, ARORA review, blood utilization review, ORYX/CHI/AFMC/CMS measures, section specific reviews and other review activities as assigned.
Understands the terms related to Super User (Lumedx/Apollo, etc.) and able to maintain and make adjustments to user restrictions as needed.
Maintains current listing of quality activities conducted for various physician specialties.
Education: RN or LPN license in the State of Arkansas: LPN required; College Degree in Basic Sciences, Business, health related sciences preferred.
Experience: Eight years health care experience with at least four in a clinical setting; strong information technology experience necessary
This job requires, at various times, the following physical activities; sitting, reaching, carrying, walking, pushing, pulling, lifting, talking, hearing, and finger dexterity.
Must have close visual acuity to perform daily activities. The worker is not substantially exposed to adverse environmental conditions.
Public speaking skills; ability to communicate effectively in verbal and / or written presentations with individuals from administrative to staff level; ability to write complex documents; ability to understand data and statistical analysis of information; ability to apply statistics to clinical settings.
PRIMARY CUSTOMERS: Physicians, management and staff.
REPORTING RELATIONSHIPS: Physicians, management and staff.
Incumbent has access to restricted or confidential patient or other highly sensitive business information and must comply with the terms of SVHS/CHI Policies as they apply to their job role.
Catholic Health Initiatives