The responsibilities of the Quality Improvement Specialist (QIS) include the following: systematic gathering and assimilation of data by which the delivery of quality patient care is measured and validated, focusing primarily on ways to improve patient care and staff performance as it relates to patient care.
The Quality Improvement Specialist (QIS) is also responsible for coordinating assigned regulatory, accreditation, clinical quality and/or service improvement programs. Monitors to ensure programs are in compliance with accreditation and regulatory requirements/ standards and monitors ongoing program performance to maintain compliance. The QIS is Responsible for implementation of the continuous quality improvement (CQI) initiatives of the Hospital.
Duties & Responsibilities:
· Provide consistent communication to the Quality Improvement Manager and Cardiovascular Leadership, ensuring that information, reports, and materials provided clearly describe QA/QI/PI activities and progress toward agreed upon objectives.
· Responsible for abstraction of concurrent and retrospective data in accordance with state (DPH and MASSDAC), federal and The Joint Commission (TJC) guidelines, NCDR, ACC and IAC (Intersocietal Accreditation Committee). Conducts ongoing review of medical records at the point of care.
· Maintains timely data entry and submission to meet all required deadlines
· Maintains up to date knowledge of the changes in data definitions and variables for reporting said data. Keeps staff current to the data definitions in order to maintain data accuracy.
· Assumes responsibility for assigned data websites, computerized data, and other computer applications
· Analyzes data for patterns or trends and opportunities to improve performance/ processes.
· Maintains confidentiality at all times.
· Upholds departmental standards for productivity, data validity, integrity, reliability and deadlines
· Maintains a working knowledge of requirements for external reporting, Pay for Reporting, Value Based Purchasing and Meaningful Use.
· Modifies and or develops and implements a comprehensive Continuous Quality Improvement Plan in accordance with Federal, State (DPH and MASSDAC) and TJC accreditation standards, NCDR, ACC and IAC.
· Facilitates Continuous Quality Improvement Teams and provides information used in maintaining a comprehensive, systematic program, while also identifying, assessing, and resolving problems, including potential problems.
· Prepares a written report of findings and recommendations for departments or committees and presents them as requested.
· Assists with the implementation of approved recommendations.
· Records and maintains all CQI activity reports
· Provides staff with education tools and training modules regarding purpose, scope, administration, and application of our CQI program.
· Leads and manages multiple complex initiatives that impact the quality or effectiveness of health care delivery and/or health care services provided to members, ensuring compliance with accreditation and regulatory requirements.
· Provides an assessment of programs, initiatives and interventions to determine the effectiveness of activities and makes recommendations to improve outcomes.
· Develops targeted activities to improve Core Measures, VBP measures, HCAHPS, provider satisfaction and other identified performance measures.
· Monitors and analyzes outcomes to ensure goals, objectives, outcomes, accreditation and regulatory requirements are met.
· Leads, facilitates or participates in relevant committees and work groups; makes presentations; prepares reports, data or other materials for committee presentation.
· Identifies areas of improvement within the hospital and works collaboratively with other departments to develop clinical and non-clinical quality/performance improvement projects.
· Researches best practices, national and regional benchmarks, and industry standards.
· In conjunction with medical staff leadership, communicates quality improvement initiatives, results, and/or performance data to Medical Staff Departments.
· Performs all other duties as assigned.