Maintains data repository and conducts analysis of activities related to Quality Management initiatives. Provides technical support in the development and analysis of data.
Supports an information system for Quality Management data aggregation; maintains Quality Management database.
Provides department chairman and quality management/ performance improvement committees with data analysis of trends, including high-risk patients/ procedures; coordinates root cause analysis and reports results to appropriate departments and regulatory agencies.
Evaluates risk management activities including monitoring of appropriate corrective actions/ improvements to render quality health care in all related phases; monitors statistical data from Quality Management reports and evaluations.
Develops systems and procedures to carry out QM/PI functions; assists in the implementation of the philosophy, goals, and objectives of the Hospital.
Participates in departmental/service Quality Improvement committees, task forces and organizational performance improvement teams as appropriate; also participates in program planning and development.
Collaborates with the multidisciplinary health care team regarding development and implementation of QM/PI program; serves as a consultant to the multidisciplinary department/service Quality Improvement Committees.
Participates as a member of the institutional Quality Management/ Performance Improvement committees in planning, reviewing, and implementing activities related to the organizational goals and objectives; recommends topics for review, including but not limited to, high risk, high volume, or problem prone activities.
Assists in the preparation process for accreditation and regulatory surveys; uses knowledge of standards of accreditation and regulatory agencies to advise and assists with assessment of adherence.
Maintains an effective reporting system to communicate and document findings, action and follow-up resulting from systematic monitoring and evaluation criteria.
Operates under general guidance and work assignments are varied and require interpretation and independent decisions on course of action.
Participates in quality management projects and initiatives.
Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here, but considered related are not essential functions.
Bachelor's Degree required, or equivalent combination of education and related experience.