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Clinical Quality Improvement Coordinator, NSQIP Surgical Reviewer

The Clinical QI Coordinator, NSQIP Surgical Reviewer is responsible for development, implementation, monitoring and analysis of appropriate methods of quality assessment/assurance and quality improvement projects and activities as part of the Hospital Quality Management Program.

• Provide ongoing support to the Hospital Quality Management Program

• Assess, analyze, and recommend quality and clinical performance improvement processes to department leadership, providers, and other appropriate disciplines

• Provide clinical expertise to assist with identification of opportunities and performance improvement activities

• Coordinate and lead clinical quality improvement projects and activities utilizing quality improvement methodologies and quality improvement cycles

• Manage various data projects, reports and dashboards pertaining to key performance indicators

• Collaborate with the Manager, Inpatient Quality Outcomes to coordinate initiatives aimed at meeting or exceeding clinical performance measure targets (for example: CMS Core Measures & Electronic Clinical Quality Measures)

• Conduct chart abstractions from medical records (example: CMS' Core Measures, NSQIP data collection)

• Identify streamlining and process improvement opportunities in the data collection process which includes identifying successes, trends, and contributing factors; develop action plans, methods to control, target dates and conclusions

• Collect, aggregate, analyze, and input data related to blood products, Core Measures, Electronic Clinical Quality Measures, Procedural Sedation, Mortality, NSQIP, and other databases or monitoring activities as assigned

• Serve as an information resource to the NSQIP Surgeon Champion, departments, and surgical service lines; serve as an educational resource on the NSQIP for internal and external audiences by developing educational material and delivering presentations

• Identify surgical patients for inclusion in the NSQIP through the application of program inclusion/exclusion criteria and protocols

• Collect pre-operative, operative and post-operative data components for the NSQIP through the effective utilization of the hospital medical record systems

• Collect and submit reliable data to the ACS NSQIP. This is accomplished through high quality data compilation, documentation and entry into the ACS NSQIP database of all eligible surgeries for the hospital.

• Demonstrates appropriate utilization of resources necessary to obtain valid, reliable data for entry into the NSQIP database

• Responsible for the accurate and timely entry of data into the NSQIP database and meets the minimum caseload requirements

• Collaborate with the members of the Department of Surgery to identify opportunities for clinical quality improvement utilizing NSQIP outcome data.

• Establish effective working relationships with members of the hospital community, especially staff in Surgery, Medicine, Nursing, Medical Records and the Information Systems Departments whose support is necessary for the management and success of the NSQIP

• Contact patients and/or families via telephone and/or written communication post-operatively for the purpose of identifying possible occurrences associated with surgical procedures performed at the hospital

• Participate in NSQIP teleconferences and webinars

• Active Indiana RN license and BSN license

• Minimum 5 years clinical experience required with at least 3 years in a hospital setting; experience in a hospital surgery department or surgical clinic preferred

• Must complete all training modules and successfully complete the ACS NSQIP SCR Training/Certification Program

• Demonstrated process/quality improvement experience required

• Experience with quality improvement methodology preferred (Lean, Six Sigma, PDSA)

• Investigative, decision making, problem solving, organization, and analytical skills required

• Ability to establish and maintain credibility and build effective relationships

• Excellent verbal and written communication skills

• Ability to present data at staff, peer, management, and committee levels

• Knowledge of medical terminology; demonstrated competence/knowledge of healthcare field

• Demonstrated knowledge of quality management processes

• Strong PC skills (including Microsoft Office applications, Visio, and database management systems) required

• Working knowledge of continuous quality improvement/performance improvement processes

• Ability to work independently; ability to facilitate groups and work within teams

• Ability to facilitate change

• Ability to prioritize, coordinate, organize, and manage multiple tasks/priorities simultaneously

• Positive self-starter and service-oriented individual

• Detail oriented with strong critical thinking skills

• Displays good judgment in apprising management of situations that are incompatible with established policies

• Ability to perform research through appropriate internet search engines