Under limited supervision, develops, maintains, and evaluates an environment that supports clinical performance improvement and excellence. Evaluates the quality and effectiveness of clinical practices and clinical services administration and abstraction of data. May participate in the review of data and analysis for the Centers for Medicare and Medicaid (CMS) core measures, physician peer review or other clinical areas as assigned.
Evaluates the quality and effectiveness of clinical practices and clinical services administration. Analyzes appropriate internal/external data and information to identify opportunities for improving services to achieve excellence. Identifies problems and issues related to clinical quality, quality outcomes measurements systems, data sources and reporting strategies and proposes courses of action to resolve issues by researching and benchmarking solutions.
Establishes standards with which to measure the effectiveness of clinical practice and services. Establishes mechanisms for data collection, data organization, and data presentation that promote the organizational philosophy of performance assessment and improvement. Fosters a professional environment promoting understanding and effective use of organization, management, and clinical theories and research.
Provides education and development to involved clinical staff, case managers and residents and providers in regards to selected indicators. Performs extensive data collection and compilation via retrospective and concurrent chart reviews; enter data into local or national database for all eligible cases. May complete daily review to ensure appropriate implementation of core measure or other indicator requirements. Interprets, presents and distributes results to a wide variety of audiences. May include feedback via individual reports or letters.
May support medical staff and interdisciplinary performance improvement committee functions and flow of information to medical staff groups and hospital departments. Collaborates effectively, efficiently and appropriately with medical staff leadership. Maintains electronic or hard copy documentation of case reviews as required. Attends relevant national conferences as required.
Performs other duties as assigned.
Knowledge of modern nursing principles, techniques, and procedures for the care of patients.
Knowledge of medical terminology, anatomy, physiology and concepts of disease.
Knowledge of Alaskan culture.
Knowledge of development, maintenance, and evaluation of patient/client and staff data collection systems and processes to support the practice of nursing and the delivery of patient care.
Knowledge of organizational systems to assure data collection for the CMS Core Measures is timely and accurate.
Knowledge of development, maintenance, and evaluation of planning systems to facilitate the delivery of clinical care that promotes desired client-centered outcomes through the clinical core business groups.
Knowledge of ICD-9 and CPT codes related to surgical procedures and Core Measure identification and ability to abstract and define surgical procedures from text.
Skill in computer applications and competence with MS Office to include word, Excel, PowerPoint, Outlook and Access.
Skill in delegating responsibilities appropriate to licensure, education, and experience of staff.
Skill in monitoring and evaluating appropriate utilization of staff.
Skill in evaluating and discerning surgical cases with appropriateness for abstraction.
Skill in developing and implementing effective educational programs and teaching groups and individuals.
Skill in communicating and relating to patients and families who are experiencing emotional, environmental, physical, social and spiritual stress.
Skill in effectively interceding with family and patients to resolve concerns related to delivery of the healthcare services.
Skill in strong written and oral communication skills.
MINIMUM EDUCATION QUALIFICATION
A Bachelors degree. Progressively responsible work experience may be substituted on a year-for-year basis for college education.
MINIMUM EXPERIENCE QUALIFICATION
Non-supervisory - Eight (8) years of experience in performance improvement or related field. An equivalent combination of relevant education and/or training may be substituted for experience.
PREFERRED EDUCATION QUALIFICATION
Bachelors degree in Nursing field is preferred. Masters Degree in a Health related field preferred.
PREFERRED CERTIFICATION QUALIFICATION
Current State of Alaska Registered Nurse licensure preferred.
Safety precautions for employees such as blood drawing for screening of various diseases such as hepatitis, required immunizations, etc. are necessary. The employee is occasionally subject to verbal abuse, threats, and physical violence from angry, hostile, or disgruntled patients and/or family members.
MINIMUM PHYSICAL REQUIREMENTS
The work involves considerable sitting, standing, and walking. Must be able to work under physically and emotionally stressed conditions. The employee is frequently exposed to communicable diseases.
ANMC is not a latex free environment. Therefore, some latex exposure can be expected.