Experience:
3-5 years of experience
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Employment Type:
Full time
Posted:
11/16/2019
Job Category:
Health Care Provider
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Quality Improvement Specialist
LifeBridge Health, Inc. | Baltimore, Maryland
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Job Description

POSITION SUMMARY: Under the direction of the Director of Quality, the Quality Improvement Specialist participates in all aspects of quality reviews, data abstraction, and data entry to ensure ongoing auditing and implementation of quality improvement initiatives, particularly around Sepsis. Conducts ongoing, comprehensive, integrated facility assessments of the quality and appropriateness of the care provided and the standards of clinical documentation in accordance to state and federal guidelines. Ensures compliance with state, federal and TJC regulations. Implements and maintains a system for identifying, collecting, analyzing and reporting of performance data.

Quality Improvement: Conducts ongoing, comprehensive, integrated facility assessments of the quality and appropriateness of the care provided and the standards of clinical documentation in accordance to state and federal guidelines. Acts an internal quality consultant for the hospital at all levels. Assists in identifying quality improvement opportunities within the organization, prioritizes the opportunities, and collaborates with leaders, project managers, and clinicians in the planning and initiating of action plans. Participates in RCAs/ACAs and event reviews, and continues follow-up on action items until event closure. Develops and enhances quality management education and infrastructure as assigned. Shares findings from quality reviews and projects with appropriate leaders and committees that support implementation and completion of effective action plans. Assists with coordination and implementation of the organization-wide Quality Plan and Program Coordinates, facilitates and reports on Quality Improvement Projects. Completes medical record reviews, compares current practice against best practice guidelines and provides recommendations to improve patient care. Supports Medical Staff Peer Review Coordinators with identifying evidence based practices to support peer review activities and actions identified from peer review trends. Supports Multidisciplinary Committees for any quality improvement activities generated. Monitors compliance with project progress relative to timelines and deadlines. Monitors impact of short and long-term compliance with implemented action items using an auditing process.

Compliance: Ensures compliance with state, federal and TJC regulations. Plays a role in ensuring compliance with all State and Federal contractual requirements regarding quality management. Collaborates with Accreditation and Regulatory Readiness staff to ensure regulatory standards are being met; participates in regulatory readiness activities; assists when there is a regulatory agency on site. Verbalizes knowledge of local, federal, and state laws and regulations as well as TJC standards related to their position. Responds to regulatory agencies quality concerns.

Data Management: Implements and maintains a system for identifying, collecting, analyzing and reporting of performance data. Participates in data collection/analysis of process or outcome measurements, including but not limited to Core Measures. Identifies patterns and trends during event reviews, and in collaboration with Risk and Patient Safety team members, identifies serious or sentinel events. Supports designing projects, coordinating and/or performing data collection, and developing action plans. Collaborates with action plan project leaders to create timelines and deadlines for each project. Gathers and enters data for clinical improvement measures, quality reviews and medical staff indicators. Prepares data for submission to appropriate departments, committees, and regulatory entities within required timeframes.

QUALIFICATIONS/REQUIREMENTS: Basic professional knowledge; equivalent to a Bachelor's degree (BSN); Nursing; 3-5 years of quality improvement/patient safety. 7+ years total experience. AHA CPR and Maryland RN License required.

Facility: Part of LifeBridge Health, Sinai Hospital of Baltimore features state-of-the-art facilities and renowned Centers of Excellence - some with national and international acclaim. As the largest community hospital and the third largest teaching hospital in Maryland, Sinai Hospital's mission is to provide quality patient care, educate medical students and residents, and engage in research to improve the lives of people all over the world. Sinai Hospital is a smoke-free workplace. M/F/PV/IWD Employer Requisition Number: 51574 Department: Sinai PI/RM - 9070 Schedule: Full-time Shift: Day shift Hours: 8:30am- 5:00pm

About LifeBridge Health, Inc.

LifeBridge health is a regional health organization that includes Sinai Hospital of Baltimore, Northwest Hospital Center, Levindale Hebrew Geriatric Center and Hospital, Jewish Convalescent & Nursing Home and related subsidiaries and affiliates.

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