Eskenazi Health serves as the public hospital division of the Health & Hospital Corporation of Marion County. Physicians provide a comprehensive range of primary and specialty care services at the 333-bed hospital and outpatient facilities both on and off of the Eskenazi Health downtown campus including at a network of Eskenazi Health Center sites located throughout Indianapolis.
FLSA Status
Exempt
Job Role Summary
The Clinical Quality Improvement Coordinator 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 Quality Management Program. This position reports to the Quality Manager.
Essential Functions and Responsibilities
Provides concurrent chart reviews on the hospital units indicating to frontline staff, Physicians and the Unit Manager of quality measures out of compliance to ensure timely follow up using both written and verbal communication along with sending weekly reports to the Unit Manager, Quality Manager and AVP of Quality and Clinical Excellence
Develops concurrent chart review audit forms and weekly report form to provide feedback to frontline staff, Physicians and the Unit Managers; investigates and analyzes deviations (both positive and negative) then communicates trends and opportunities in written reports to Unit Managers, Physicians and appropriate healthcare leaders
Provides education to specific groups for performance improvement such as at unit staff meetings, flyers with quality measure information and tips, Resident Training and skills fair; posts quality measure data on learning boards in hospital staff break rooms
Acts as a change agent with frontline staff, Physicians and Unit Managers with focus on documentation improvements and effectiveness
Responsible for development, implementation, monitoring and analysis of appropriate methods of quality assessment/assurance and quality improvement projects and activities as part of the Quality Management Program
Interacts with all internal and external customers in a caring and respectful manner in accordance with our Core Values philosophy
Provides ongoing support to the quality of care provided to our patients and families
Manages projects and activities for patient safety and quality
Participates in service excellence, accreditation activities and initiatives
Provides input and recommendations to the quality management team for quality and safety projects and initiatives
Manages various data projects, reports and dashboards pertaining to key performance indicators
Ensures that project plans include measurements of program and individual outcomes, productivity measures, and are in compliance with all applicable legislative and accrediting organizations
Works with direct supervisor to coordinate initiatives aimed at meeting or exceeding clinical performance measure targets (for example: CMS Core Measures)
Leads clinical quality improvement projects
Coordinates quality improvement and risk management activities
Leads teams through standardized quality improvement methodologies and quality improvement cycles
Conducts chart abstractions from medical records (example: CMS' Core Measures)
Identifies streamlining and process improvement opportunities in the data collection process which includes identifying successes, trends, and contributing factors then develops action plans, methods to control, target dates and conclusions
Completes targeted audits as requested and as deemed necessary by leadership
Collects, aggregates, analyzes and inputs data related to blood products, Core Measures, Specialty Physician Incentive Measures, Conscious Sedation, Mortality, Falls, Critical Lab Values and other databases or monitoring activities as assigned
Supports risk management and medical staff services
Job Requirements
Bachelor's degree in health care or business related field required; OR four years of experience working in quality, data analysis, managed care and/or utilization tracking
Active RN license in the state of Indiana required
Clinical Nurse Specialist Advanced Practice Certification preferred
One year of managing cross-functional projects required
Improvement plan development experience preferred
Lean or Six Sigma training preferred; or experience with Six Sigma or other quality improvement methodology
Two years of recent Quality Management experience preferred
Experience with Medicaid Managed Care preferred
CPHQ certification preferred or willingness to become CPHQ certified over time
KNOWLEDGE, SKILLS, AND ABILITIES:
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 in interactions with various levels of management
Ability to present data at staff, peer, management and committee level
Knowledge of medical terminology; demonstrated competence/knowledge of healthcare field
Demonstrated knowledge of quality management processes
Strong PC skills (including Excel, Access, Visio, other reporting database management systems) required
Working knowledge of Continuous Quality Improvement / Performance Improvement process
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 for which there is little precedence
Ability to perform research through appropriate internet search engines
Knowledge, Skills & Abilities
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 in interactions with various levels of management
Ability to present data at staff, peer, management and committee level
Knowledge of medical terminology; demonstrated competence/knowledge of healthcare field
Demonstrated knowledge of quality management processes
Strong PC skills (including Excel, Access, Visio, other reporting database management systems) required
Working knowledge of Continuous Quality Improvement / Performance Improvement process
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 for which there is little precedence
Ability to perform research through appropriate internet search engines
Accredited by The Joint Commission and named as one of Indiana's best employers by Forbes magazine for two consecutive years and the top hospital in the state for community benefit by the Lown Institute, Eskenazi Health's programs have received national recognition while also offering new health care opportunities to the local community. As the sponsoring hospital for Indianapolis Emergency Medical Services, the city's primary EMS provider, Eskenazi Health is also home to the first adult Level I trauma center in Indiana, the only verified adult burn center in Indiana and Sandra Eskenazi Mental Health Center, the first community mental health center in Indiana, just to name a few.