Full Job Description 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 processes, assigned registries, NRC patient experience information and reporting, Vizient Clinical Database/Resource Manager, CMS core measures collection and reporting, and AMC analytics (QlikView) applications such as the Readmission Explorer and Population Explorer. Communicate proactively with physicians as needed for queries regarding documentation gaps that influence risk adjusted measures. Collaborate with physician subject matter experts to explore and communicate opportunities to improve measure rates. 12. Perform in depth real time and retrospective chart reviews for applicable patients.

PROFESSIONAL SKILLS

: Adhere to the highest standards of ethical conduct as defined by AMC and the tenets of the profession. Read and independently analyze documents such as regulatory rules or measure collection specification manuals. Document on established forms, translating manuals to the AMC EMR. Assist in presentations or project design related to start-up or summarizing results. Be accurate in such matters as record keeping and researching before providing an answer. Ability to promote and assist with the creation of AMC's policies, procedures and practices as it relates to assigned areas of expertise or measures. Properly delegates and coordinates work assignments with support staff and analysts, ensuring staff understand completely before starting work.

COMMUNICATION SKILLS

Constantly connects with services, departments, and assignments to build knowledge of operations, seek process improvement opportunities and build relationships. Communicates cooperatively and effectively to clients and others. Ability to listen well, engage in interactive dialogues and facilitate communication among separate groups. Influences others through use of evidence-based practice and documents successes. Leads subgroups when needed, seeking input to achieve consensus and helping with conflict resolution. Properly escalates items for resolution collaborating together with the Assistant Director when needed.

MATHEMATICAL SKILLS

: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent. Utilize knowledge of experimental design, descriptive and inferential statistics and statistical process control for reporting or evaluation.

PHYSICAL DEMANDS

: While performing the duties of this job, the employee is regularly required to stand, walk, use hands to type, probe, handle, or feel objects, tools, or controls, reach with hands and arms, and speak and hear. The employee is required to sit for extended periods of time in an office environment, attending to a desktop computer and monitor. Specific vision abilities required include close vision, distance vision, peripheral vision, depth perception, the ability to adjust and focus and ability to see small font in order to translate to a data entry form on a computer monitor.

WORK ENVIRONMENT

: The noise level in the work environment is usually moderate to low and includes conversations happening in the same room, such as another co-worker having a phone conversation.

OTHER REQUIREMENTS

: All job requirements listed indicate the minimum level of knowledge, skills, and/or ability deemed necessary to perform the job proficiently. This job description is not to be construed as an exhaustive statement of duties, responsibilities, or requirements. Employees will be required to perform any other job-related instructions given by their supervisor subject to reasonable accommodations. Thank you for your interest in Albany Med Health System! Albany Med Health System is an equal opportunity employer. This role may require access to information considered sensitive to Albany Med Health System, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a \"need to know\" and is the minimum necessary to properly perform assigned duties. 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