Job Overview

Employment Type:

Full time

Shift:

Description:

POSITION PURPOSE:
Supports the Quality Excellence Department and medical staff departments in identified projects and improvement efforts, in order to enhance hospital and medical staff outcome and service initiatives. Assists in the development of statistical reports (to include physician credentialing) to promote data driven decision-making throughout the hospital. Utilizes performance improvement methodology and data analysis to assist and guide organization-wide performance improvement efforts as well as medical staff improvement and peer review. Facilitates medical staff meetings through agenda preparation, presenting performance improvement data/analysis, and taking minutes for the meetings. Assists with education of physicians and hospital staff members as it relates to integrating and improving performance. Acts as a liaison between MercyOne Dubuque Medical Center and medical staff to strengthen and maintain positive relationships with physicians on behalf of MercyOne.

Accurately abstracts patients’ medical records for data required by the Centers for Medicare/Medicaid Services, (CMS) to assure acquisition of scheduled Medicare payment increases, necessary for the continued operations of the hospital. Accurately abstracts data from patients’ medical records related to multiple indicators as required by the medical staff, Joint Commission, Trinity Health, and other national health care databases. Participates in hospital committees to present the data and analysis, and provides input to corrective action plans to improve patient care and outcome.

SCOPE OF SERVICE:
Customers include: physicians, physician office staff, Medical Services Coordinator, nurses, Executive Team members, Health Information Management personnel, vendors, Trinity Health staff, government representatives, and others on the health care team.

ESSENTIAL FUNCTIONS:
1. Adheres to the principles of caring and expected behavior outlined in MercyOne Dubuque Medical Center's Model of Caring and Trinity Health's Code of conduct, fostering a climate where all customers are treated in a manner consistent with MercyOne Dubuque Medical Center's Mission and Values.
2. Maintains a working knowledge of applicable Federal, State and local laws and regulations, Trinity Health’s Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.
3. Demonstrates knowledge, skills and abilities to perform quality improvement activities and medical record chart abstractions to include, but not limited to: CMS core measures, Trinity Health measures, NDNQI measures, ORYX measures, medical staff measures, and selected measures related to data collection for national data bases.
4. Accurately interprets clinical information in the medical record including but not limited to physician documentation, diagnostic tests, medications, procedures, and nursing assessments.
5. Maintains a group chart abstraction validation rate > to 80% for CMS measures, ensuring the hospital’s receipt of Medicare’s full annual reimbursement increase.
6. Actively participates in the “Getting to Green” meetings as scheduled. Reports successes and deficiencies related to selected indicators. Participates in action planning and follow-up to improve patient care and services.
7. Attends and participates in Trinity Health’s monthly Quality Contacts call, and applies information to current quality activities.
8. Participates in periodic CMS or IFMC audio conference calls, WebEx education, and other Internet communications related to CMS indicator manual revisions and other updates.
9. Participates on the Nursing Performance Improvement Committee, and other hospital committees.
10. Develops and appropriately disseminates physician outcome reports to be utilized in the medical staff credentialing, privileging, and reappointment processes.
11. Participates as needed in other activities related to physician credentialing, privileging, reappointment, and peer review.
12. Works closely with the Coordinator of Medical Staff Services to ensure compliance with CMS and Joint Commission requirement related to medical staff and allied health providers.
13. Oversees the function and follow-through activities of several medical staff committees.
14. Oversees the development and submission of articles/communication for the medical staff newsletter and other methods of communication with physicians, and their offices staffs.
15. Analyzes and interprets information to ensure requesters receive reports that are accurate, valid and reliable, and displayed in a useable and meaningful way to include usage of a variety of statistical and performance improvement tools.
16. Prepares agendas and takes minutes of medical staff department and other medical staff monitoring committees.
17. Exhibits sound judgment, critical thinking, problem solving and decision making skills.
18. Demonstrates the ability to work independently, and the ability to work collaboratively in a team environment.
19. Interfaces and collaborates with many individuals and departments such as administration, nurses, physicians, physician office personnel, Trinity Health Corporation, and other members of the health care team.
20. Demonstrates general knowledge of computers. Demonstrates specific knowledge related to software programs to include, but not limited to Cerner/PowerChart, Internet, and other software programs related the collection of data for applicable national databases.
21. Performs other duties consistent with the purpose of the job as directed.

SKILLS AND ABILITIES REQUIRED:
1. Maintains a professional, collaborative work environment so as to foster a positive public image for MercyOne Dubuque Medical Center.
2. Knows and adheres to all laws and regulations pertaining to patient health, safety and medical information (i.e. HIPAA, Stark, etc.).
3. Provides a high level of customer responsiveness and serves as a role model to encourage a commitment to customer service. A strong service orientation is required.
4. Maintains an excellent working relationship within the department and with all of our internal and external customers.
5. Ability to handle interactions with discretion, tact and courtesy when dealing with sensitive issues and confidential information.
6. Must have excellent written and verbal communication skills with the ability to relate to people across all levels and diverse backgrounds.
7. Ensures that services are provided in a manner that supports continuous quality improvement and customer-oriented focus.
8. Keeps supervisor informed about important issues.
9. Demonstrates an understanding of organizational dynamics and administrative procedures and protocols. Ability to function in a dynamic, fast-paced team environment and to cope with ambiguity, time constraints, and other daily stressors in an effective and appropriate manner.
10. Demonstrates time management, prioritization and organizational skills including an ability and willingness to plan, organize and accomplish tasks accurately and in a timely manner to exercise sound judgment under pressure and to manage multiple and competing activities simultaneously.
11. Must be able to work independently and productively in a fast paced setting involving multi-task functions and projects. Ability to plan, organize and perform duties with minimal supervision and with a high degree of accuracy and attention to detail.
12. Proven ability to identify, compile and present data effectively from many different sources for management decision-making.
13. Must possess advanced analytical skills.
14. Ability to demonstrate initiative.
15. May be required to increase/decrease work schedule and/or vary hours depending on the needs of the department.

PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS:
1. During an 8-hour day, an employee must be able to sit for 3 hours, stand for 3 hours and walk for 1 hour.
2. Job requires occasional (<10% of work time) squatting, crawling, crouching, kneeling, and balancing; frequent (21-50% of work time) bending, stooping, reaching above shoulder level, pushing and pulling.
3. Job requires the ability to frequently (21-50% of work time) lift and carry objects weighing approximately 11-24 pounds.
4. Must have fine motor and manual dexterity skills to grip and manipulate items and perform repetitive action such as computer entry.
5. Requires visual acuity, the ability to speak and the ability to hear speech.
6. Job requires high level of mental concentration to attain established deadlines. Working environments includes frequent interruptions.
7. Must be able to travel on occasion to other worksites and training seminars.
8. Must adhere to applicable organizational requirements on an annual basis for Employee Health Directives.

MINIMUM QUALIFICATIONS
(EDUCATION, LICENSURE, CERTIFICATION, AND EXPERIENCE REQUIRED):
1. Education, Licensure and Certification:
A. BSN or Bachelors in health care-related field.
B. Current RN license to practice nursing in Iowa where work is performed.
2. Experience:
A. Three to five years' clinical experience.
B. Previous employment as a quality specialist preferred.
C. Previous experience abstracting medical records preferred.
D. Previous hospital performance improvement experience preferred.
3. Special Skills, Competencies, and Aptitudes:
Demonstrated experience and competency with Microsoft Office Suite, e-mail and a variety of web-based programs and browsers, with the willingness and ability to update and increase skills as needed to meet the goals of the departments. Ability to use other software as required to perform the essential functions of the job.

ADDENDUM (IF APPLICABLE)
Quality Excellence Specialist – Infection Prevention (IP)
ADDITIONAL ESSENTIAL FUNCTIONS:
1. Assists Mercy Infection Prevention Specialist/Infection Preventionist with daily duties of the IP program/plan
2. Assists with monitoring IP audits/data collection of: hand hygiene, isolation, MDRO, central line bundle compliance, ventilator events etc.
3. Assists with surveillance for Dubuque and Dyersville.
4. Assists IP with investigations of significant clusters of infections above expected levels and analysis of data.
5. Assist when needed for educational opportunities (Nursing Grand Rounds, Nursing Practice Fair)
6. Performs other duties consistent with purpose of job as directed.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.