This position is responsible for supporting systematic organization-wide Performance Improvement, the medical staff peer review activities on quality of care and comparative data and focus studies in accordance with the PI plan, Medical Staff Bylaws, Rules and Regulations and the Peer Review policy and procedure. Has knowledge of relational databases and medical information systems and statistical methods and applications. Possesses data visualization and presentation skills, both written and verbal. Also responsible for promoting and supporting Performance Improvement and Quality Assessment activities throughout the organization by offering data and analysis substance for the teams. Supports the design, assessment, and measurement of important processes and outcomes that may affect the delivery of quality patient care, operational processes and strategic initiatives. Has working knowledge of the Balanced Scorecard and its linkages to quality studies and measurement.

Work Schedule

8 a.m. to 5 p.m. Monday through Friday and occasional weekends depending on the needs of the hospital.

Primary Duties

Quality Sciences:

• Supports quality activities in accordance with the Performance Improvement Plan.
• Supports the systematic organization-wide peer review program as assigned. (See Medical Staff Activities)
• Maintains the statistical reporting, data entry and database management for programs as required and assigned.
• Supports the Performance Improvement Committee meetings and activities as assigned.
• Assists Director, Performance Improvement with project status and development.
• Provides to the Director, Performance Improvement for the governing board, administrative and medical staff bodies required quality reports containing findings from data collection, analysis and review activities as needed.
• Maintains working knowledge of the medical staff and governing body bylaws, rules and regulations and affiliated policies and procedures.
• Finds, reviews and corrects data to support regulatory requirements per regulatory updates and other memorandums.
• Serves as the content expert for all assigned databases.
• Makes process recommendations based on results of data from assigned databases.
• Participates in chartered and needed quality team activities as assigned.
• Supports and promotes the scientific methodologies of quality (i.e., PDCA, Lean, and DMAIC).
• Ensures collection, assessment and analysis of data occurs for teams, selected processes studied, clinical practices, operational and clinical outcomes, and other pertinent functions.
• Reports data using statistical and scientific methods.
• Assists the Director, Performance Improvement on team process: closes the loop on quality studies in a timely manner and implements a control plan to maintain the gain and prevent process or system entropy.
• Enters data into the Midas system or other spreadsheet function for analysis and reporting of variation; and, supports the system administrator for Midas.

Medical Staff Activities:

• Supports the PI Analyst II on data entry for ACC, STS, Core Measures and other programs as required and assigned.
• Uses Midas to provide quality profile information for the medical staff reappointment process from the assigned databases.
• Supports medical staff peer review activities on quality of care, comparative data and focus studies in accordance with the PI plan and Peer Review policy and procedure.

Qualifications/Specifications:

• Education: High school diploma or equivalent required. Associate degree or Bachelor of Science degree in data analysis, statistics or equivalent preferred. Specialized training in statistical process control (SPC), Performance Improvement, Quality Assessment and Assurance, and Regulatory Management required. Training and education in Performance Improvement tools and techniques required.
• Licensure/Certification: None required. LVN, PCP or other healthcare Professional preferred. Green Belt certification preferred.
• Experience: Minimum of five years in one of the following areas: clinical nursing, health information management or other clinical/hospital specialty required.