JOB TITLE

Clinical Quality Analyst (RN)

DEPARTMENT

Quality Management

REPORTS TO

Quality Management Director

JOB SUMMARY

The Clinical Quality Analyst (CQA) supports the hospital's Quality, Risk & Patient Safety programs by collecting, validating, analyzing, visualizing and reporting of data used to monitor performance, patient safety, regulatory compliance, and quality improvement initiatives. Partners with clinical and administrative staff to collect and compile data, perform medical chart reviews, prepare performance reports, quality measure abstraction, submit data for mandatory reporting. Collaborates with Medical Staff Office to manage, maintain and improve Ongoing Professional Practice Evaluation (OPPE) process and help with collection, analysis, and reporting of practitioner performance data to support safe, high-quality patient care and evidence-based credentialing decisions. Partners with IT/Informatics to design and implement data collection and reporting processes using various software applications. The CQA maintains quality databases, dashboards and scorecards and serves as a resource for quality metrics and clinical outcome monitoring. The CQA has overall knowledge of regulatory requirements and functions of medical staff and clinical departments and promotes a culture of data-driven continuous improvement.

JOB REQUIREMENTS

Current Wyoming licensure as a Registered Nurse. Bachelor's degree in nursing preferred. Master's degree in statistics, informatics, computer science, epidemiology a plus. Proficiency in data tools such as Excel and EMR systems; SQL a plus. Solid understanding of medical terminology & clinical workflows; knowledge of core healthcare quality metrics (e.g. core measures, infection prevention, etc.) a plus.

EXPERIENCE 4

years working in a hospital or clinical setting required. Experience with eCQMs and chart abstraction preferred. 1 year experience with healthcare data analysis and interpreting clinical metrics; college level course work in statistics a plus. Epic Slicer Dicer and other Epic reporting experience preferred. Experience with Midas Care Management functions a plus, e.g. building custom forms, tracking lists, daily work tasks; creating reports, system administration, support & training; willingness to become a Midas super-user. Experience in quality management and/or leading performance improvement projects a plus. SKILLS Must possess a high degree of confidentiality in all matters with the ability to manage sensitive and confidential situations with tact, professionalism, and diplomacy. Must have strong interpersonal skills with the ability to communicate with staff and public in a friendly, courteous and helpful manner. Excellent communication skills required with people of varying levels of education and authority both internal and external to the organization. Must be able to interact effectively with a wide variety of people. Possess the ability to read, write and verbally communicate effectively in English. Understanding of patient safety principles and regulatory requirements. Knowledge of healthcare quality measurement concepts and national standards. Strong critical thinking and problem-solving skills. Ability to interpret quality measures and communicate insights effectively. Ability to work independently with high attention to detail. Ability to establish and maintain a spirit of cooperation and respect and engage in professional and ethical conduct. Demonstrate effective leadership and creativity to improve outcomes for patients/residents. Ability to write reports and other forms of correspondence. Ability to effectively present verbal and/or written information. Ability to respond to the most sensitive inquiries or complaints. Must be self-directed, motivated, and organized, with the ability to prioritize multiple tasks based on organizational needs. Strong computer and keyboarding skills. Ability to navigate hospital EMRs. Must be proficient in the use of Microsoft Office Suite products including Word, Excel, Outlook and PowerPoint. Ability to learn new computer software applications. High functioning team skills, including active listening and rapport building; exhibits strong customer service orientation.

REQUIRED CERTIFICATIONS CPHQ

required within 24 months of hire. Epic Certified Report Writer/Analyst certification, a plus.

ESSENTIAL FUNCTIONS

Health Data Analytics Collect, validate, and maintain quality-related data from clinical, operational, and administrative systems. Ensure data integrity; troubleshoot and resolve data discrepancies among different data sources and applications. Identify, document, resolve and/or escalate data issues and maintain an issues log. Collaborate with IT and Informatics to optimize data capture processes and ensure data reliability. Maintain documentation of data sources, definitions, and analytical methodologies; create metadata to ensure continuity of operations and reproduction of data deliverables and analyses. Organize and manage data sets needed for internal dashboards, safety reporting, and regulatory submissions. Perform data analysis using statistical techniques to identify trends, variation, and opportunities for improvement. Develop and maintain clear, intuitive visualizations (dashboards, scorecards, run charts, control charts). Provide general data education and support for staff unfamiliar with data interpretation. Collaborate with IT and Informatics to design & define focus studies create and customize data collection forms, implementing skip logic, input validation, and user authentication to ensure clean data entry by staff; build and configure automated SmarTrack rules within Midas to mine hospital data and accurately capture patients meeting focus study criteria. Configure and run reports from Midas. Performance and Process Improvement. Partner with clinical and operational teams to provide data support for quality improvement (QI) projects. Track project metrics and outcomes, ensuring baseline and post-intervention data are reliable and reproducible. Translate analytical findings into actionable insights and communicate them to multidisciplinary teams. Patient Safety and Risk Management. Assist Risk Manager by extracting and analyzing data related to adverse events, near misses, safety culture survey, and harm measures. Monitor performance on safety measures in collaboration with Risk Manager. Identify emerging risks and patient safety issues for further study from routine chart review, data collection and surveillance activities. Regulatory and Accreditation. Support reporting for CMS, state agencies and other regulatory and accreditation bodies, as directed. Maintain current familiarity with measure specifications and reporting requirements. Assist with audit, inspection, site visit preparation by supplying requested data, metric interpretation, and reports. Monitor performance on regulatory metrics, identify compliance gaps and opportunities for improvement. Professional Practice Evaluation Collaborate with Quality, Risk Management, Compliance and Medical Staff Services to ensure that the OPPE program integrates with broader quality initiatives. Participate in development or enhancement of OPPE dashboards/scorecards, data collection tools, and workflows. Collect, validate, and analyze practitioner performance data using approved quality and peer review metrics. Collaborate with clinical, administrative and support departments to define, update, and refine specialty-specific OPPE indicators. Support Medical Staff Services to complete the OPPE process for privileged practitioners in accordance with NAMMS guidelines and regulatory requirements. Population Health Management Identify data and resources that are important in determining the health status and risk factors of defined populations e.g. disease-specific, service-line, setting, etc. Analyze and use clinical, cost, equity, and social determinants of health data to drive and monitor improvement efforts in collaboration with Case Management, Social Services, the Utilization Review team, Quality, Infection Control and department leaders.

Location:

Cody Regional Health

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QUALITY MANAGEMENT

Schedule:

Full Time (80 pp), Days