Clinical Quality Specialist

Summary The Clinical Quality and Performance Improvement (PI) Specialist RN manages Centers for Medicare & Medicaid Services (CMS) and state quality reporting programs and leads clinical quality improvement initiatives related to those measures. The Specialist serves as a subject matter resource for staff, leaders, and providers on CMS and state quality measures and applicable regulatory requirements. Responsibilities include sepsis data abstraction; promotion of evidence-based sepsis care across the hospital; coordination and submission of the Leapfrog Hospital Survey; and analysis of safety data to identify trends, gaps, and actionable improvement opportunities. The Specialist collaborates with leaders, providers, and staff to advance established performance improvement priorities and achieve hospital quality goals. The role also conducts project-based chart reviews, benchmarking, data analysis, reporting, and staff education in support of quality and performance improvement initiatives. Essential Duties and Responsibilities The duties and responsibilities below describe the general scope of the role. Additional duties may be assigned as needed. Quality Management and Chart Abstraction Develops and maintains current knowledge of CMS and state quality measure requirements, including the interpretation and application of requirements to evaluate compliance. Serves as a resource for CMS quality programs, including the Hospital Inpatient Quality Reporting (IQR), Hospital Outpatient Quality Reporting (OQR), Promoting Interoperability (PI), Hospital Value-Based Purchasing (VBP), Hospital Readmissions Reduction (HRRP), Hospital-Acquired Condition Reduction (HACRP), and CMS hospital Quality and Patient Experience Star Rating programs. Serves as an authorized Security Official for the Hospital Quality Reporting (HQR) system; downloads and maintains hospital-specific CMS reports; supports report interpretation and analysis; and conducts related quality and performance improvement activities. Reviews medical records to evaluate compliance with established quality measure criteria; conducts detailed analyses to identify performance gaps; recommends improvement opportunities; and leads related performance improvement initiatives. Evaluates, validates, and ensures the accurate and timely submission of electronic clinical quality measure (eCQM) data in accordance with CMS requirements. Evaluates compliance with CMS structural measures and develops plans to maintain ongoing compliance. Assists the Director and Quality Data Analyst with other CMS, state, and Joint Commission ORYX data submissions, as needed. Ensures the complete and accurate collection, validation, and maintenance of CMS quality measure data, including abstracted measure data. Designs and delivers education for medical and clinical staff on documentation practices related to quality measures and reinforces the interpretation of measure criteria, as needed. Serves as the liaison to the Quality Improvement Organization (QIO), as needed. Serves as a vital member of the Sepsis Committee; may include preparing agendas and meeting materials; facilitating meetings; and managing follow-up actions. Performs sepsis and other assigned measure abstraction; compiles and analyzes clinical data; and produces reports that identify trends for operational leaders, providers, and designated quality committees. Assists with implementing evidence-based sepsis protocols, educates clinical staff, tracks patient outcomes, and supports compliance with the CMS sepsis quality measure (SEP-1), as needed. Leapfrog Safety Survey Maintains current knowledge of Leapfrog Hospital Survey requirements and the process and outcome measures used in the Leapfrog Hospital Safety Grade. Collaborates with process owners and the Patient Safety Specialist to complete the Leapfrog Hospital Survey, verify that requirements are met, and maintain supporting documentation. Partners with Informatics and Information Technology to coordinate the Leapfrog computerized provider order entry (CPOE) evaluation; identifies and prepares the internal testing team; and develops and implements plans to optimize results. Analyzes Leapfrog safety data to identify trends, gaps, and actionable improvement opportunities, and prepares summary reports for stakeholders and leaders. Translates Leapfrog safety findings into measurable performance improvement plans designed to strengthen the hospital's safety culture and Leapfrog Hospital Safety Grade: prepares summary reports. Performance Improvement Uses established problem-solving methodologies, such as Define, Measure, Analyze, Improve, and Control (DMAIC) and Plan, Do, Study, Act (PDSA), to participate in or lead teams, work groups, projects, and activities that improve patient outcomes, operational performance, and processes. Provides ongoing analysis and trending of patient safety and quality data, including mortality, readmissions, and complications of care. Uses data to develop graphs, dashboards, and quality reports for leaders, committees, and providers. Ensures performance improvement initiatives are managed using a data-driven approach. Recommends annual improvement priorities aligned with strategic quality objectives. Ensures required data are collected in a timely manner, distributes regular progress reports for active projects, and recommends additional improvements based on findings. Conducts project-based chart reviews and provides staff education in support of performance improvement initiatives. Assists with agenda planning for the hospital Quality Committee and presents reports, as assigned. Hospital Accreditation Support Assists the Director with survey readiness and survey management activities to support compliance with CMS, state, and Joint Commission standards. Develops plans of correction and completes evidence-of-compliance documentation, as needed, in collaboration with the Director, process owners, and operational leaders. Assists with the annual Joint Commission survey application and facilitates notifications of new services, as required. Coordinates ongoing compliance audits and survey rounds to ensure adherence to applicable standards, and supports survey readiness committees, as assigned. Other Duties Manages assigned projects independently and resolves issues within the scope of the role. Represents the department on designated multidisciplinary teams and committees. Supports clinical operations and initiatives, as assigned. Attends required hospital-wide orientations, meetings, and in-service education. Maintains professional knowledge and skills through seminars, workshops, continuing education, and professional affiliations to remain current with trends and practices in the field. Performs other duties as assigned, including coverage of essential department functions and services. Education and Experience Minimum Required Education: Graduate of an accredited registered nursing program. A Bachelor of Science in Nursing (BSN) is preferred; relevant experience may be considered in lieu of the degree. Preferred Education: Bachelor of Science in Nursing (BSN). Experience: At least three years of experience in data abstraction, informatics, or electronic medical record documentation analysis, and at least five years of clinical nursing experience. Proficiency with standard business applications, including Microsoft Excel, PowerPoint, and Word. Knowledge of performance improvement methodologies is preferred. Licenses and Certifications Current license to practice as a Registered Nurse in the State of Tennessee is required. The incumbent must obtain Certified Professional in Healthcare Quality (CPHQ) or Certified Professional in Patient Safety (CPPS) certification within 18 months of hire and maintain active certification throughout employment. #J-18808-Ljbffr Nashville General Hospital