This position is responsible for sustaining 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. The PI Analyst II must have data visualization and presentation skills, both written and verbal. This position must have the ability to teach various audiences about data, interpretation and limitations and can prioritize multiple requests for data analysis.

The PI Analyst II is also responsible for promoting and supporting Performance Improvement and Quality Assessment activities throughout the organization by offering data and analysis substance for PI teams. The position is actively involved in the design, assessment, and measurement of important processes and outcomes that may affect the delivery of quality patient care, operational processes and strategic initiatives. This position is also responsible for assisting the Director of Performance Improvement in the implementation, support, direction and further enhancement of clinical data and tracking mechanisms, including assisting the CSC in support of all Clinical Research Processes at the facility as needed.

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:

1. Sustains quality activities in accordance with the Performance Improvement Plan.
2. Sustains the systematic organization-wide peer review program. (See Medical Staff Activities)
3. Maintains the statistical reporting for ACC, STS, CORE Measures, GWTG, and other programs as required and assigned.
4. Facilitates and supports the Performance Improvement Committee meetings and activities as needed.
5. Assists PI Director with project status and development.
6. Provides to the PI Director for the governing board, administrative and medical staff bodies required quality reports containing findings from data analysis and review activities as needed.
7. Demonstrates a working knowledge of the medical staff and governing body bylaws, rules and regulations and affiliated policies and procedures.
8. Analyzes, finds and corrects data to support regulatory requirements per regulatory updates and other memorandums.
9. Serves as the content expert for all assigned areas, data and tracking mechanisms.
10. Makes process recommendations based on results of data analysis from assigned areas.
11. Participates in chartered and needed quality team activities as assigned.
12. Supports and promotes the scientific methodologies of quality: i.e. PDCA, Lean, and DMAIC.
13. Ensures that collection, assessment and analysis of data occurs for teams, selected processes studied, clinical practices, operational and clinical outcomes, and other pertinent functions.
14. Reports data using statistical and scientific methods.
15. Assists the PI Director on team process: close the loop on quality studies in a timely manner and develop and implement a control plan to maintain the gain and prevent process or system entropy.
16. Responsible for entry of 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:

1. Provides education to medical staff members on data from ACC, STS, Core Measures and other programs as required and assigned.
2. Provides quality profile information for the medical staff reappointment process from the assigned resources.
3. Assesses, evaluates and monitors specific quality of care concerns and perform special studies as necessary, and report findings to the appropriate committees as assigned
4. Actively participates in and support 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.Relationship Building:

1. Accepts positive and negative constructive feedback.
2. Demonstrates a supportive/positive attitude toward the hospital and fellow employees.
3. Demonstrates a teaching and consultative approach to the quality sciences.
4. Provides and identifies resources and shares as appropriate.
5. Participates in education and development programs.
6. Maintains and promotes a team spirit through active cooperation and collaboration.
7. Fosters team development through the use of team building and development tools.

Results Oriented:

1. Ability to demonstrate measurable results and achievements.
2. Effective in cost control and resource utilization.
3. Maintains and develops personal professional competency through the use of a learning plan.
4. Effective at taking action on analyzed data, improvement opportunities and then bringing the actions to closure in a timely manner.
5. Data entry, analysis and actions are accurate, timely and pertinent.

Customer Service Indicators:

1. Maintains positive relationships with internal and external customers.
2. Proactive in meeting the customers needs by using appropriate quality science tools.
3. Responds promptly to customer needs or requests.

Leadership and Role Modeling:

1. Expresses self in an organized, comprehensive, articulate and concise manner.
2. Participates with performance improvement group and other best practice and task force teams through conference calls and meetings as needed.
3. Demonstrates extensive use of the Midas program for quality and credentialing services.
4. Supports strategic planning, balanced scorecard and business planning efforts as needed as assigned;

Critical Thinking Application:

1. Demonstrates consistent approach of balancing ownership and accountability to all participants.
2. Is statistically minded using inductive and deductive reasoning when problem solving.
3. Uses resources appropriately to augment personal skills and knowledge to help achieve world-class quality outcomes for the hospital.
4. Effectively uses selected and approved computer system and programs to manage projects, data and reports.

Project Management:

1. Supports quick turnaround of two days for most quality efforts.
2. Provides PI Director with project and data analysis / management updates.
3. Meets deadlines for regulatory compliance and project completion.
4. Manages processes effectively for ACC, STS, Core Measurement, CMS, PRO, and Interqual studies via data abstraction, analysis, action plans and reporting as assigned.

Regulatory Compliance:

1. Assists in compliance with JCAHO, Medicare, and State standards as needed.
2. Assists with mock survey processes as needed.
3. Works in tandem with the PI Director to achieve full compliance with regulations.

Qualifications/Specifications:

• Education: Bachelor of Science degree in Nursing required. 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: Licensed as a Registered Nurse. Green Belt certification preferred.
• Experience: Minimum of five years in clinical nursing required. Cardiac Critical Care nursing strongly preferred. ACC, STS and Core Measure expertise needed for this position. Has demonstrated knowledge of relational databases and medical information systems and statistical methods and applications.