Quality & Patient Safety Advisor (Per Diem)

capecodhc; Hyannis (MA); On-site; USD 95,000 - 125,000; Full time

Job summary

Cape Cod Hospital is seeking a Quality Improvement professional to lead data abstraction for core measures, monitor the reliability of definitions, and support regulatory reporting. You will collaborate with clinical educators, coders and frontline staff to implement evidence-based initiatives, coordinate PDCA cycles, and prepare reports and improvement plans for internal customers.

This role also ensures timely submissions to CMS, BoRM, TJC and DPH, and maintains proficiency in MIDAS and

Qualifications

• RN license required.
• Baccalaureate Degree in Nursing required; Master’s degree preferred.
• CPHQ certification or proven experience in quality improvement and regulatory compliance preferred.
• Effective communication, presentation and facilitation skills required.

Responsibilities

• Lead data abstraction for quality measures following regulatory manuals.
• Monitor data entry for reliability of core measure definitions.
• Maintain up-to-date knowledge of data definitions and reporting requirements.
• Ensure data accuracy and meet submission timelines for required entities.
• Coordinate PDCA-based improvement initiatives with clinical staff and educators.
• Prepare reports and improvement plans; support QA initiatives and task forces.
• Assist in peer review activities and ensure regulatory compliance alignment.

Skills

Communication skills

Presentation & facilitation

Data analysis & presentation

Collaborative teamwork

Education

Bachelor's degree in Nursing

Master's degree in Nursing or related field

CPHQ certification (preferred)

Tools

MIDAS

DataVision

Job description

1. Quality Improvement

• Responsible for the data abstraction of all applicable data measures with strict adherence to the specifications manuals provided by the regulatory body.
• Demonstrates applicability of methodology and reliability of definitions of the Core Measure data elements through careful monitoring of data entry into MIDAS (incident reporting system)
• Maintains current working knowledge of the changes in data definitions and variables for reporting data measures as assigned.
• Responsible for data accuracy, meeting submission timelines for all required entities as assigned by Executive Director.
• Responsible for searching external databases and web sites to keep current on all data submission requirements and specifications and using data abstraction tools to produce meaningful analyses and correlation of data.

Process and Systems Improvement:

• Collects, aggregates, analyzes, and reviews data for improvement opportunities
• Coordinates efforts in the development and implementation of action plans to resolve identified clinical/process issues utilizing the PDCA rapid cycle methodology.
• Collaborates with clinical educators, coders and other staff to serve as a resource regarding core measures requirements and other quality initiatives.
• Utilizes identified national benchmarks and standards of care in the development of action plans for QI/PI.
• Supports a hospital-wide culture for continuous quality improvement
  • Facilitates and collaborates in the designing of new processes that develop/monitor quality indicators
  • Establishing innovative processes to improve quality
  • Preparing reports and improvement plans
  • Consulting on quality monitors, including data collection, sample size, and analytical tools
  • Supporting our Performance Improvement/Patient Safety /Quality initiatives and taskforces
• Maintains proficiency in the use of MIDAS+, DataVision and, all other databases as assigned.

Program Development:

• Collaborates with respective Quality/Safety Program leaders, sponsors, advisors, content experts, and frontline champions on implementing evidence-based initiatives and monitoring process and outcome measures related to their program(s)
• Partners with Program leaders on program evaluation and identification of opportunities for improvement.

Public Reporting and Internal Reporting:

• Assesses clinical and non-clinical outcomes using the measurement systems established, including data collection analysis and correlation and dissemination of information to internal customers.
• Responsible for searching external databases and using data abstraction tools to produce meaningful analyses and correlation of data in simple, understandable graphic format for internal customers.

Peer Review:

• Under the guidance of the CMO, assists the Medical Staff and Department Chiefs with peer review activities.
• Organize findings, actions and recommendations and oversee the maintenance of the MIDAS peer review database. Provide trend analysis of physician specific quality data for re-appointment purposes and performance improvement initiatives
• Assists the Executive Director, Quality, the Medical Director, the Chief of Staff and the Chief Quality Officer to ensure the compliance of the Medical Staff with TJC Standards, DPH Conditions of Participation, OSHA regulations and the BoRM PCA semi-annual reporting as assigned

2. Patient Safety

Regulatory Compliance:

• Elicits support necessary to obtain valid, reliable data for reporting to regulatory agencies by remaining current with the regulations/standards and/or requirements as defined by these agencies eg. Center for Medicare and Medicaid (CMS), Board of Registration in Medicine (BoRM), the Joint Commission (TJC), Department of Public Health (DPH).
• Maintains current knowledge of all Regulatory changes/Updates and communicate changes to Hospital committees, taskforces and teams as appropriate
• Coordinates activities with Executive Director for successful accrediting, licensing, and certification survey activities as assigned by service line (including but not limited to TJC, DPH, CMS, BoRM)
• Collaborates with Quality team and respective service line leaders in coordinating completion of the Semi-Annual Quality Analysis Reports for submission to the BoRM.
• Participates in Root Cause Analysis (RCS's) and (Failure Mode and Effect Analysis (FMEA's) as assigned and facilitates process change based on the findings of these activities. Provide support to staff for monitoring and summarizing the effectiveness of the process change
• Provides feedback to management on process improvement initiatives, dashboard data, and indicator screening trends as assigned by service line or committee.

Other Duties:

• Specific Service line/Program responsibilities as assigned.

Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers in a manner that reflects Cape Cod Hospital's commitment to CARES: compassion, accountability, respect, excellence and service.

• RN license required
• Baccalaureate Degree in Nursing required, Master's Degree preferred
• CPHQ preferred or proven experience in quality/process improvement and regulatory compliance
• Effective communication skills
• Excellent presentation and facilitation skills
• Demonstrated competence in quality data analysis and presentation
• Minimum of 5 years of experience in Hospital with progressive experience in quality improvement preferred
• Minimum of 5 years of experience in Quality Database and/or system management preferred