Job Summary:
This position reports to the Director of Organizational Excellence. This individual will analyze data to evaluate the performance in quality improvement, develop and implement activities to improve overall patient experience, claims based and quality measures as measured by nationally standardized benchmarks and definitions. This candidate will be responsible for various duties, including medical record auditing, associated with the continuous monitoring, maintenance, and improvement of quality throughout the organization. Lead and participate in special projects as directed and perform other duties as assigned. Maintains and manages the job-related quality and regulatory assignments, including preparing and distributing reports, submitting quality data, and assisting with the coordination of committee and regulatory survey logistics. Manages processes to ensure accuracy and completeness of work. Knowledgeable of department policies and quality procedure appropriate to the position. Works collaboratively with the team to complete required area of responsibilities and special assignments.
Duties and Responsibilities:
Ensures that home care and hospice services comply with regulatory standards and accreditation requirements.
Develop and implement quality improvement projects to enhance patient care and safety.
Conduct regular audits of patient records and care processes to assess the quality of care provided.
Gather and analyze data related to patient outcomes, identifying trends and areas for improvement.
Work closely with other healthcare professionals, including physicians, nurses, and therapists, to coordinate care and improve patient outcomes.
Maintain accurate and detailed records of quality improvement activities and patient outcomes, and report findings to relevant stakeholders.
Collaborate and coordinate with organization-wide QI staff to develop/review all processes involved in monitoring, delivery of care, regulatory requirements which impact agency care processes.
Investigate incidents and adverse events to determine their root causes and develop strategies to prevent recurrence.
Subject matter expert in clinical nursing practice, quality and management of complex conditions.
Supports and facilitates both quality and clinical team relationships including care, risk, quality, and compliance work streams.
Responsible for assisting with the development of programs and initiatives for quality monitoring and performance improvement throughout the organization.
Assists the staff with the development of best practices and guides the implementation of evidence-based practice where applicable.
Assists with the development of guidelines, criteria, and clinical indicators, which are applied to measure quality of care.
Compiles data and information for departmental projects and presentations.
Prepares documents and reports that are accurate complete and within required time frames.
Maintains all department documents and files so they are complete, accurate and retrievable.
Manages changes to existing policies, procedures, and processes, and prepares new ones.
Assures policy/procedure binders and computer files/folders are up-to-date and accurate. Archives/scans old policies as they become outdated.
Coordinates and arranges meetings, prepares agendas, reserves, and prepares meeting facilities, records, & transcribes meeting minutes in an accurate, timely, confidential manner.
Conducts and coordinates projects as assigned; prepares and presents findings in an organized fashion, ensures timely completion of assignments.
Creates charts, graphs, and displays data appropriately.
Assists with chart review processes related to quality measures for both home care and hospice.
HIS/HOPE data set and OASIS data set
- Review charts and identifies areas that need correction.
- COPs Assist with chart review process and collection of data.
Patient /Family Experience
Prepares and distributes individual team and staff quality outcome and HHCAHPS reports.
Serves as support for TJC, State surveys, quality committee and other initiatives as needed.
Accesses and utilizes the Joint Commission site, SHP, Shared Point, EMR, and keeps current on processes or IS upgrades to systems workload.
Requirements:
Bachelor prepared Registered Nurse or master’s degree level. Preferred equivalent experience in Quality and Performance Improvement, Joint Commission and CMS principles and methodology knowledge required.
Working knowledge of and proficiency in the use of Windows based PC system including Microsoft Outlook, Word, Excel Access and PowerPoint. Ability to plan, organize and lead data collection and the ability to navigate and evaluate medical records/ EMR. Demonstrated competency in office/administrative procedures and ability to work in multiple platforms/regulatory systems.
Care New England Health System (CNE) and its member institutions, Butler Hospital, Women & Infants Hospital, Kent Hospital, VNA of Care New England, Integra, The Providence Center, and Care New England Medical Group, and our Wellness Center, are trusted organizations fueling the latest advances in medical research, attracting the nation’s top specialty-trained doctors, and honing renowned services and innovative programs to engage in the important discussions people need to have about their health.
Americans with Disability Act Statement: External and internal applicants, as well as position incumbents who become disabled must be able to perform the essential job-specific functions either unaided or with the assistance of a reasonable accommodation, to be determined by the organization on a case-by-case basis.
EEOC Statement: Care New England is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status
Ethics Statement: Employee conducts himself/herself consistent with the ethical standards of the organization including, but not limited to hospital policy, mission, vision, and values.
