Quality Specialist

Department/Unit: Quality Management Work Shift: Day (United States of America) Salary Range: $94,957.00 - $147,183.00 The Quality Specialist is responsible for providing guidance to department managers, teams and staff in the analysis, management and improvement of the processes and systems of the organization using continuous quality improvement (CQI) and Plan, Do, Check, Act (PDCA) principles. The individual is responsible for helping leaders ensure a quality program is maintained throughout the organization, insofar as the program requires analysis, collection, reporting and use of performance improvement material and techniques. This is accomplished through training in and applying performance improvement tools and techniques, researching and presenting evidence-based practice/literature, providing benchmarking, collection or analysis support and other duties as assigned. This position has a significant impact on the organization through supporting regulatory requirements, directly managing authoritative clinical registries, leading or participating in performance improve initiatives, and assisting clinical and administrative departmental managers in addressing clinical quality. QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  EDUCATION and/or EXPERIENCE REQUIRED: Current Registered Nurse (RN), Nurse Practitioner (NP), Physician Assistant (PA) or Physician credentials (MD / DO) If RN, Master's degree or above required Minimum of six years experience in a health care setting   OR   6 years experience in a full-time role directly supporting performance improvement, such as within a LEAN or Six Sigma program PREFERRED: Additional education or certifications in quality improvement / patient safety related topics. Examples include: CPHQ, CPHRM, inferential statistics, LEAN, Six Sigma, Team STEPPS, IHI program education certification. Any of the aforementioned may be acceptable for replacing portions of the 6 year minimum requirement for work experience at the discretion of hiring manager and HR department. MAJOR TASKS, DUTIES AND RESPONSIBILITIES: Plays an integral role as a clinical improvement change agent with a primary focus on mortality review, applying clinical experience to clinical performance improvement measures or goals.  Advocates for the patient using the Institute of Medicine’s six domains of health care quality: safe, effective, patient-centered, timely, efficient and equitable. Builds knowledge to become a content expert (CE) in all assigned regulatory, registry or internal priority quality measures related to mortality.  Understands not only the abstraction rules and measure definition, but also the standards set forth by governing bodies for the whole process; vendor tool use, data file submission/feeds, abstraction and completion of records, quarterly / annual report use, and all deadlines associated.  Advocates for more efficient processes in support of the above. As a CE, performs independent chart audits and reviews data elements for assigned measures (CMS, Leapfrog) data extraction for assigned measures and registries. Supports and / or attends mortality and morbidity review meetings, working together with the assigned service contact to ensure follow-up and closure of all case referrals and issues. Collaborates with Risk Management staff as needed. Uses CQI and PDCA concepts, principles, tools and techniques.  Seeks to build knowledge of the AMC LEAN approach including, at minimum, Green Belt achievement.  Demonstrates ability to apply the right tool in support of the programs, teams or topics assigned.  Manages continuing education constantly and proactively through attending relevant conferences within assigned registries/programs/topics, reviewing quality improvement resources such as: DNV, CMS, NYSDOH, using training material provided by governing agencies of registries (AHA, ASA, NYSDOH, TJC etc.), AMC LEAN program web site, HANYS web site, Vizient web site, IHI web site, and/or other nationally recognized programs in specialty topics assigned. Serves effectively on teams as a consultant and CE by: Assisting in development and/or selection of clinical quality measures and goals, including meeting with physician leaders, service directors and/or team leaders when necessary Assisting in the design of data collection strategies based on assigned focus for departmental quality programs and process improvement teams, linking teams to best data streams / reports / external department resources (HIS, CLD, Lean, Analytics, Epidemiology, etc.) Assisting with research of best practice or querying sources such as listserves to understand how other academic facilities meet similar challenges Assisting the team leaders to communicate project methods and results widely throughout the organization, suggesting resources such as Center for Learning and Development, policy changes, etc. Promoting appropriate recognition of the accomplishments of team members and leaders Suggesting appropriate mechanisms are put in place when improvement teams have completed work to audit periodically and hold the gains Understands collection and reporting process for the Vizient Safety Intelligence (SI) patient occurrence data. May be requested to look for trends or opportunities for improvement with assistance from analysts in QM. Is an advanced user of the EMR including building knowledge not only of lookup/navigation, but also of work flow, entry points and entry timing. Understands when to seek help such as from Clinical Informatics staff. Is an intermediate to advanced end-user of applications, systems or programs which contain clinical performance improvement information useful in driving change. Examples include mortality and morbidity collection and reporting proc