Srh, Quality Measure Coordinator

Wentworth-Douglass Hospital Charlestown , MA 02129

Posted 7 months ago

Summary

Collaborates with leadership, clinical, health information, compliance, in managing ongoing documentation oversight and training for inpatient clinical staff. Focus areas include but are not limited to: accuracy of functional status (GG, FIM) and quality measures - pressure injuries, infections, falls, cognitive/mental status, drug regimen review, medication reconciliation and physician IRF specific documentation requirements. Partners with inpatient team members to maximize accuracy of documentation and associated scoring and to achieve consistency between clinical documentation, quality measures, and assessment scores. Assures accuracy of documentation and QM; minimizes variances with national and regional data. Optimizes reimbursement through accurate scoring. Ensures compliance with the US FIM/GG credentialing program and CMS QM regulation. Participates in applicable committees.

Key Responsibilities

  • Manages a comprehensive, continuous training program of clinical staff on all shifts to maximize comfort level, skill, and inter-rater reliability with assessment process and accurate FIM/GG and QM scoring. Provides education through a variety of methods, beginning with new employee orientation, skills fairs, e-mail instruction, participation in staff meetings, 1:1 instruction.

  • Assesses consistency of assessment information between IRF- PAI entries and clinical documentation; works with CDI, Coding and Outcomes colleagues to develop metrics and report effort.

  • Follows up as applicable with front line staff and reports findings and identifies areas for focused process improvement to department managers and appropriate committees on a regular basis.

  • Assesses variances with national data; reports findings and collaborates with leadership team to develop focused process improvement initiatives.

  • Consults with nursing, therapy and informatics managers to design, maintain, and evaluate data collection tools to meet established goals for the improvement and maintenance of FIM/GG/QM accuracy.

  • Collaborates with Outcomes Manager to maintain UDS credentialing program.

  • Oversees electronic documentation system (Medilinks, Epic) training; partners with informaticists.

  • Tracks impact of FIM/GG documentation in UDS to identify opportunities for improvement and financial impact.

  • CARF and Joint Commission outcomes management and performance measurement standards are monitored to ensure compliance.

  • Participates in interdisciplinary committees to advance established goals.

  • Additional department, organization, or network activities are completed per established objectives.

  • PCC Organizational Values of Innovation, Collaboration, Accountability, Respect, and Excellence are upheld.

  • Adheres to and promotes SRN compliance standards.

Qualifications and Experience

Education/Degree

Required

  • Current MA license in Nursing, Physical Therapy, Occupational Therapy, or Speech/Language Pathology

Experience

Required

  • 5 years' experience working in a health care setting

Preferred

Strong preference for experience in a rehabilitation setting; experience in health care data analysis desired.

Licensure

Required

  • Current Massachusetts license as a Registered Nurse or Allied Health field required.

Skills (Specific learned activity gained through training (e.g. computer skills, keyboarding, presentation, CPR, ACLS, etc.)

Required

  • Ability to critically analyze findings and identify trends. Ability to apply basic statistics. Exposure to research design and evaluation techniques desired.

  • Computer proficiency required. Microsoft office applications preferred with ability to learn new software.

Preferred

  • Highly developed communication and interpersonal skills, working with diverse populations.

  • Work independently, be self-directed and contribute as a member of a team.

  • Anticipate challenges; able to develop and implement strategies for addressing them.

  • Committed to a high level of service delivery. Demonstrates initiative with ability to prioritize work, meet deadlines and adapt to changing situations.

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Srh, Quality Measure Coordinator

Wentworth-Douglass Hospital