Job Description

JOB SUMMARY

Under theleadership of the Manager of Quality and Safety, the Clinical Quality Reviewer (CQR) is responsible for the collection and accurate submission of data through workstations and the identification of opportunities for quality improvement. The CQR works in collaboration with Physician Champions, medical staff, leadership, the Quality Improvement team, and front-line employees to use data to improve patient outcomes. Strives for superior performance by consistently providing a product or service to leadership and staff and is recognized as ultimately contributing to the patient and family experience.


PRIMARY JOB RESPONSIBILITIES

1. Data Collection and Reporting

• Responsible for collecting, analyzing and reporting clinical data elements on eligible cases as required for participation in Collaborative Quality Initiative (CQI).
• Independently manage the case load and report data to Collaborative according to established standards and deadlines.
• Identifies patients for inclusion in the program(s) through the application of program inclusion/exclusion criteria and protocols.
• Identifies the appropriate resources necessary in obtaining valid, reliable data for entry into the program(s).
• Demonstrates effective utilization of the hospital medical records systems in the collection of data components specific to the program(s).
• Identifies opportunities for streamlining and process improvement in the data collection process.
• Utilizes software applications for data collection and analysis.
• Responsible for the accurate and timely entry of the data into the program databases and meets the caseload accrual requirement protocol.
• Reviews weekly site accrual report on the database and responds to accrual reports alert (as applicable).
• Maintains regular contact with the physician champion(s) and other members of the team at Memorial Healthcare.
• Prepares for and is available for site audits.
• Attends Collaborative-wide meetings and sub-group meetings as a representative of Memorial Healthcare.
• Acts as a resource regarding the Collaborative within Memorial Healthcare.
• Resolves data discrepancies, and responds to HMS coordinating Center requests in a timely fashion.

1. Core Measure Abstraction

• Performs chart abstraction for selected measures related to the CMS/Joint Commission Core Measures and others as assigned. Maintains abstraction accuracy of at least 90% as validated by internal and external audits.
• Performs concurrent review of key core measure processes to ensure timely compliance.
• Collects data for other selected hospital quality initiatives including but not limited to: Michigan Hospital Association initiatives, Midas, The Joint Commission and Leapfrog.
• Collects data for measures related to Pay for Performance and Value Based Purchasing initiatives.
• Conducts chart review for other indicators such as medical, surgical, maternal or fetal complications, mortalities, readmission, sepsis and hospital acquired conditions as requested.
• Analyzes data for trends and improvement opportunities.
• Creates reports and presentations of data in appropriate formats for individual and audience presentations.
• Presents quality data at assigned medical staff department meetings, including recommendations for improvement and facilitation of group discussion.

1. Quality Improvement

• Actively engage in Collaborative activities and identify opportunities to improve the quality of care and patient outcomes at Memorial Healthcare by working with physicians, nurses, other clinicians, and administrators to develop strategies to improve performance.
• Collaborates with the Physician Champions to use data in identifying opportunities for Quality Improvement.
• Plays key role in the development of Quality Initiatives based on data.
• Implements best practices recommendations as appropriate and in collaboration with relevant individuals and/or groups.

1. Works Effectively with Patients, Families, and Staff

• Establishes effective working relationships with members of the hospital community, especially staff in the Emergency Department, Medicine, Nursing, Medical Records, Infection Control, Quality/Patient Safety, and the Information Systems Departments whose support is necessary for the management and success of the program.
• Contacts physician offices and/or clinics via telephone and/or written communications as necessary to facilitate collaborative objectives.
• Contacts patients and/or families via telephone and/or written communications as necessary to facilitate collaborative objectives.
• Serves as an educational resource for internal and external audiences by developing educational material, delivering presentations, and disseminating data.

1. Additional Memorial Healthcare Responsibilities

• Acts as system administrator for assigned software programs.
• Participates in various hospital committees and teams as assigned.
• Researches literature to support quality improvement and patient safety activities.
• Maintains current knowledge of quality initiatives and pending changes required from regulatory bodies or other external agencies.
• Works collaboratively with other departments to achieve quality improvement goals.
• Acts as a resource to Memorial Healthcare Departments for quality improvement issues.
• Prepares and presents educational information and/or tools related to quality as indicated.
• Ensures that the use and retention of quality improvement and peer review information meets established policies.
• Demonstrates knowledge of and supports hospital mission, vision, value statements, standards of behavior, policies, operating instructions, confidentiality statements, corporate compliance plan and the code of ethical behavior.
• Delivers consistently excellent customer service to patients, co-workers, volunteers, and others. Specifically, listen and ask questions for understanding, always ask how else you can help, follow-up to ensure that an issue has been resolved.
• Act as a public relations ambassador for Memorial Healthcare at all times. Specifically, speak positively about the organization; manage up co-workers, managers, and others.
• Have a working knowledge of Memorial Healthcare services; reports issues, problems and suggestions to the appropriate person in a timely manner.
• Enhances personal growth through participation in internal and external education programs.

1. Demonstrates knowledge of and supports hospital mission, vision, value statements, standards, policies and procedures, operating instructions, confidentiality statements, corporate compliance plan, customer service standards, and the code of ethical behavior.

DEPARTMENTAL AND ADDITIONAL JOB RESPONSIBILITIES

1. Other duties as assigned

JOB SPECIFICATIONS

EDUCATION

1. Unencumbered license as a registered nurse in the state of Michigan required
2. Bachelor of Science Degree in Nursing (BSN) or Bachelor Degree (BS) preferred

EXPERIENCE

1. Ability to complete all pre-training, on-site training modules and to pass the training posttest.
2. Minimum one year experience in healthcare setting.
3. Clinical chart review and abstraction experience is highly recommended but not required.
4. Quality improvement and/or patient safety knowledge and experience preferred.

ESSENTIAL PHYSICAL ABILITIES/MOTOR SKILLS

1. Able to travel independently throughout all Memorial Healthcare facilities.
2. Small motor skills required for operating modern computer, office, and telephone equipment as utilized by Memorial Healthcare.

ESSENTIAL TECHNICAL ABILITIES

1. Proficiency using modern office, computer and telephone equipmentas used by Memorial Healthcare.
2. The ability to learn and utilize new software and web applications for data entry and report generation.
3. Must have computer experience with MS Office, as well as working knowledge of computer software (Microsoft Word and Excel) and basic statistical skills.

ESSENTIAL MENTAL ABILITIES

1. Ability to adapt and maintain focus in fast paced, quickly changing or stressful situations.
2. Ability to read and interpret a variety of documents including, but not limited to policies, operating instructions, white papers, regulations, rules and laws.
3. The ability to collect data and identify areas for quality improvement requiring clinical knowledge and understanding of patient care. Be skilled in understanding and interpreting clinical data.
4. The ability to successfully communicate and collaborate with multidisciplinary teams to implement data driven quality improvement initiatives/programs.
5. Experience with the ability to locate and gather information in a complex hospital system through various sources such as medical records, surgery clinics, social security death index, direct patient contact, and accounts payable. The ability to identify opportunities to present MSQC data to relevant groups or meetings (for example: M&M, infection control, quality management, and administration).

ESSENTIAL SENSORY REQUIREMENTS

1. Able to see for the purpose of reading information received in formats including but not limited to paper, computer, reports, bulletins, updates, manuals.
2. Able to hear for work-related purposes.

INTERPERSONAL SKILLS

1. Ability to interact with co-workers, hospital staff, administration, patients, physicians, the public and all internal and external customers in a professional and effective, courteous and tactful manner, at all times, physically, verbally and in all written and electronic communication.
2. Required to remain calm when adversity is encountered.
3. Open, honest, and tactful communication skills.
4. Ability to work as a team member in all activities.
5. Positive, cooperative and motivated attitude.
6. Ability to maintain confidentiality.

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