Company:
MyMichigan Health
Location: Saginaw
Closing Date: 22/10/2024
Hours: Full Time
Type: Permanent
Job Requirements / Description
Summary:
The Data/Performance Improvement Specialist RN II is responsible for collecting, analyzing and reporting clinical data elements on eligible cases as required by the specified Collaborative Quality Initiative (CQI) or any other third party, where there is a contractual agreement. In conjunction with lead physician, administrative lead, manager, service line lead/director, and other clinical resources, utilizes collaborative outcome data to identify and implement quality improvement programs. Coordinates, collects, and submits data to external registries as defined by scope of collaborative. In collaboration with Manager, works with external third-party auditors to ensure that standards are being met, performance improvement is occurring, and outcomes are being monitored on an ongoing basis. Queries and collates patient study information for Manager, Physicians, Quality Committees, Strategic Business Line Director/ Service Line Director or Lead for the preparation of reports and presentations. Assists in quality improvement initiatives that further the mission vision and values of MyMichigan Health through the priorities of the trauma admin and quality and safety department. This role resides in the Michigan Trauma Quality Improvement Project (MTQIP) and as such also has the following summation of work: Reporting to the Trauma Program Manager, the Michigan Trauma Quality Improvement Project (MTQIP) Data/Performance Improvement Specialist is responsible for all aspects of trauma quality assurance (QA) and performance improvement (PI). This position is specifically responsible for meeting all requirements related to PI and QA set forth by the Michigan Trauma Quality Improvement Project (MTQIP), the American College of Surgeons Trauma Quality Improvement Project (TQIP), verification standards of PI/QA for adult level two trauma centers from the ACS, any PI/QA standards set forth by the State of Michigan, and any MyMichigan Health related PI/QA project related to trauma care.
Responsibilities:
(30%)* In conjunction with lead physician, administrative lead, manager, service line lead/director, and other clinical resources, utilizes collaborative outcome data to identify and implement quality improvement programs.
(30%)* Coordinates, collects, and submits data to external registries as defined by scope of collaborative.
(25%)* Collaborates with Manager to work with external third party auditors to ensure that standards are being met, performance improvement is occurring, and outcomes are being monitored on an ongoing basis.
(15%)* Queries and collates patient study information for Manager, Physicians, Quality Committees, Strategic Business Line Director/ Service Line Director or Lead for the preparation of reports and presentations.
Each of these distributions include trauma specific detail that includes:
MTQIP / TQIP:
Accurately collects any data points requested or required by MTQIP / TQIP.
Validation of data and accuracy for all MTQIP / TQIP data collected and registered.
In collaboration with the Trauma Data Registrar, responsible for data entry of all MTQIP / TQIP data points in timely and accurate manner that meets or exceeds all MTQIP standards.
Responds to all MTQIP / TQIP e-mails within time standards set forth by MTQIP/TQIP.
Attends and participates in all MTQIP / TQIP meetings to the requirements set forth by MTQIP / TQIP.
Analyzes MTQIP / TQIP data and identifies areas for improvement within the MyMichigan Medical Center-Midland trauma program.
In collaboration with the Trauma Program Manager (TPM), plans, implements, monitors, and insures loop closure on all identified areas for improvement related to MTQIP / TQIP.
Coordinates and oversees all required MTQIP / TQIP data submission calls.
Coordinates and oversees all required MTQIP / TQIP data validation reviews.
Reports MTQIP / TQIP data as appropriate via mechanisms such as e-mail, trauma dashboard, committee reports, and any other appropriate method.
Verification, Designation, and Internal:
Accurately collects, validates, and analyzes all PI/QA data required for verification by the ACS or designation by the State of Michigan.
Accurately collects, validates, and analyzes all PI/QA data related to any trauma program project or standard identified by the TPM, Trauma Medical Director (TMD), Trauma PIPS committee, or Trauma M&M committee.
Identifies opportunities for trauma performance improvement and collaborates with appropriate parties to create innovative solutions.
Identifies and reports trauma performance and/or quality issues that require review by Trauma PIPS committee, Trauma M&M, or any other appropriate review body.
Participates in Regional and State trauma system and meets any requirement of MyMichigan Medical Center-Midland related to performance improvement and/or quality.
In collaboration with the TPM, coordinates the trauma performance improvement and patient safety program.
In collaboration with the TPM, plans, implements, monitors, and insures loop closure on all identified areas for trauma performance improvement.
Reports performance and quality data as appropriate via mechanisms such as e-mail, trauma dashboard, committee reports, and any other appropriate method.
Assists with preparation and site visit for any trauma program review including, but not limited to, ACS verification visits and State designation review visits.
OTHER DUTIES AND RESPONSIBILITIES:
Attends, coordinates and facilitates regularly scheduled quality improvement meetings to share relevant data.
Attends all mandatory training and meetings as required by CQI Coordinators.
Works with other team members for cross coverage and assistance on project work.
Demonstrates and maintains positive interpersonal skills interdepartmentally, in order to promote positive outcomes.
MyMichigan Health is a technology driven organization and employees need to demonstrate competency in Microsoft? Windows. An employee may be required to participate in further learning opportunities offered by MyMichigan Health.
Other duties as performance measures change to ensure relevancy for quality and safety goals of MyMichigan Health and MTQIP.
Certifications and Licensures:
Credential:ACLS: Advanced Cardiac Life Support
Equivalent Experience: Within 12 months of hire or transfer
Qualification Source:
Essential: true
Credential:BLS: Basic Life Support
Equivalent Experience: Within 3 months of hire or transfer
Qualification Source: AHA
Essential: true
Credential:RN: Registered Nurse
Equivalent Experience:
Qualification Source: MI
Essential: true
Required Education:
Education: BACH
Equivalent Experience: In addition to the required BSN, a Master of Science in Nursing (MSN) or masters degree in business, data analytics, health administration preferred.
Education Specialization: NRG
Essential: true
Other Information:
EXPERIENCE, TRAINING AND SKILLS:
Proficient computer skills for the facilitation of data collection, query, and management required.
Experience in providing education/reports.
Interpersonal skills needed to communicate successfully with individuals and groups and interact with people at all levels to communicate ideas and concepts in a clear, concise, and understandable manner.
Critical thinking and analytic skills required.
High degree of accuracy and deductive thinking skill required.
Knowledge of anatomy, physiology, pathophysiology, and disease processes and medical terminology preferred.
One year experience in data collection, query or in an allied health field preferred.
Five years clinical nursing experience or experience in analyzing and interpreting processes, clinical outcomes and costs of care preferred.
Fundamental knowledge of performance improvement processes preferred.
Strong computer skills facilitating data collection and management with experience providing education/reports to groups of clinicians preferred.
Experience working at a verified and/or designated trauma center or in performance/quality management preferred.
Trauma Nurse Core Course (TNCC) and/or Trauma Care after Resuscitation (TCAR) preferred.
PHYSICAL/MENTAL REQUIREMENTS AND TYPICAL WORKING CONDITIONS:
Exposure to stressful situations, including those involving public contact, as well as, trauma, grief and death.
Able to wear personal protective equipment that includes latex materials or appropriate substitute if required for your position.
Is able to move freely about facility with or without an assisted device and must be able to perform the functions of the job as outlined in the job description.
Overall vision and hearing is necessary with or without assisted device(s).
Frequently required to sit/stand/walk for long periods of time. May require frequent postural changes such as stooping, kneeling or crouching.
Some exposure to blood borne pathogens and other potentially infectious material. Must follow MyMichigan Health bloodborne pathogen and TB testing as required.
Ability to handle multiple tasks, get along with others, work independently, regular and predictable attendance and ability to stay awake.
Overall dexterity is required including handling, reaching, grasping, fingering and feeling. May require repetition of these movements on a regular to frequent basis.
Physical Demand Level: Sedentary. Must be able to occasionally (0-33% of the workday) lift or carry 0-10 lbs.
Equivalent Experience and Other Comments (Education):
Education: BACH
Equivalent Experience: In addition to the required BSN, a Master of Science in Nursing (MSN) or masters degree in business, data analytics, health administration preferred.
Education Specialization: NRG
Essential: true
Other Comments:
Credential:ACLS: Advanced Cardiac Life Support
Equivalent Experience: Within 12 months of hire or transfer
Qualification Source:
Essential: true
Credential:BLS: Basic Life Support
Equivalent Experience: Within 3 months of hire or transfer
Qualification Source: AHA
Essential: true
Credential:RN: Registered Nurse
Equivalent Experience:
Qualification Source: MI
Essential: true
The Data/Performance Improvement Specialist RN II is responsible for collecting, analyzing and reporting clinical data elements on eligible cases as required by the specified Collaborative Quality Initiative (CQI) or any other third party, where there is a contractual agreement. In conjunction with lead physician, administrative lead, manager, service line lead/director, and other clinical resources, utilizes collaborative outcome data to identify and implement quality improvement programs. Coordinates, collects, and submits data to external registries as defined by scope of collaborative. In collaboration with Manager, works with external third-party auditors to ensure that standards are being met, performance improvement is occurring, and outcomes are being monitored on an ongoing basis. Queries and collates patient study information for Manager, Physicians, Quality Committees, Strategic Business Line Director/ Service Line Director or Lead for the preparation of reports and presentations. Assists in quality improvement initiatives that further the mission vision and values of MyMichigan Health through the priorities of the trauma admin and quality and safety department. This role resides in the Michigan Trauma Quality Improvement Project (MTQIP) and as such also has the following summation of work: Reporting to the Trauma Program Manager, the Michigan Trauma Quality Improvement Project (MTQIP) Data/Performance Improvement Specialist is responsible for all aspects of trauma quality assurance (QA) and performance improvement (PI). This position is specifically responsible for meeting all requirements related to PI and QA set forth by the Michigan Trauma Quality Improvement Project (MTQIP), the American College of Surgeons Trauma Quality Improvement Project (TQIP), verification standards of PI/QA for adult level two trauma centers from the ACS, any PI/QA standards set forth by the State of Michigan, and any MyMichigan Health related PI/QA project related to trauma care.
Responsibilities:
(30%)* In conjunction with lead physician, administrative lead, manager, service line lead/director, and other clinical resources, utilizes collaborative outcome data to identify and implement quality improvement programs.
(30%)* Coordinates, collects, and submits data to external registries as defined by scope of collaborative.
(25%)* Collaborates with Manager to work with external third party auditors to ensure that standards are being met, performance improvement is occurring, and outcomes are being monitored on an ongoing basis.
(15%)* Queries and collates patient study information for Manager, Physicians, Quality Committees, Strategic Business Line Director/ Service Line Director or Lead for the preparation of reports and presentations.
Each of these distributions include trauma specific detail that includes:
MTQIP / TQIP:
Accurately collects any data points requested or required by MTQIP / TQIP.
Validation of data and accuracy for all MTQIP / TQIP data collected and registered.
In collaboration with the Trauma Data Registrar, responsible for data entry of all MTQIP / TQIP data points in timely and accurate manner that meets or exceeds all MTQIP standards.
Responds to all MTQIP / TQIP e-mails within time standards set forth by MTQIP/TQIP.
Attends and participates in all MTQIP / TQIP meetings to the requirements set forth by MTQIP / TQIP.
Analyzes MTQIP / TQIP data and identifies areas for improvement within the MyMichigan Medical Center-Midland trauma program.
In collaboration with the Trauma Program Manager (TPM), plans, implements, monitors, and insures loop closure on all identified areas for improvement related to MTQIP / TQIP.
Coordinates and oversees all required MTQIP / TQIP data submission calls.
Coordinates and oversees all required MTQIP / TQIP data validation reviews.
Reports MTQIP / TQIP data as appropriate via mechanisms such as e-mail, trauma dashboard, committee reports, and any other appropriate method.
Verification, Designation, and Internal:
Accurately collects, validates, and analyzes all PI/QA data required for verification by the ACS or designation by the State of Michigan.
Accurately collects, validates, and analyzes all PI/QA data related to any trauma program project or standard identified by the TPM, Trauma Medical Director (TMD), Trauma PIPS committee, or Trauma M&M committee.
Identifies opportunities for trauma performance improvement and collaborates with appropriate parties to create innovative solutions.
Identifies and reports trauma performance and/or quality issues that require review by Trauma PIPS committee, Trauma M&M, or any other appropriate review body.
Participates in Regional and State trauma system and meets any requirement of MyMichigan Medical Center-Midland related to performance improvement and/or quality.
In collaboration with the TPM, coordinates the trauma performance improvement and patient safety program.
In collaboration with the TPM, plans, implements, monitors, and insures loop closure on all identified areas for trauma performance improvement.
Reports performance and quality data as appropriate via mechanisms such as e-mail, trauma dashboard, committee reports, and any other appropriate method.
Assists with preparation and site visit for any trauma program review including, but not limited to, ACS verification visits and State designation review visits.
OTHER DUTIES AND RESPONSIBILITIES:
Attends, coordinates and facilitates regularly scheduled quality improvement meetings to share relevant data.
Attends all mandatory training and meetings as required by CQI Coordinators.
Works with other team members for cross coverage and assistance on project work.
Demonstrates and maintains positive interpersonal skills interdepartmentally, in order to promote positive outcomes.
MyMichigan Health is a technology driven organization and employees need to demonstrate competency in Microsoft? Windows. An employee may be required to participate in further learning opportunities offered by MyMichigan Health.
Other duties as performance measures change to ensure relevancy for quality and safety goals of MyMichigan Health and MTQIP.
Certifications and Licensures:
Credential:ACLS: Advanced Cardiac Life Support
Equivalent Experience: Within 12 months of hire or transfer
Qualification Source:
Essential: true
Credential:BLS: Basic Life Support
Equivalent Experience: Within 3 months of hire or transfer
Qualification Source: AHA
Essential: true
Credential:RN: Registered Nurse
Equivalent Experience:
Qualification Source: MI
Essential: true
Required Education:
Education: BACH
Equivalent Experience: In addition to the required BSN, a Master of Science in Nursing (MSN) or masters degree in business, data analytics, health administration preferred.
Education Specialization: NRG
Essential: true
Other Information:
EXPERIENCE, TRAINING AND SKILLS:
Proficient computer skills for the facilitation of data collection, query, and management required.
Experience in providing education/reports.
Interpersonal skills needed to communicate successfully with individuals and groups and interact with people at all levels to communicate ideas and concepts in a clear, concise, and understandable manner.
Critical thinking and analytic skills required.
High degree of accuracy and deductive thinking skill required.
Knowledge of anatomy, physiology, pathophysiology, and disease processes and medical terminology preferred.
One year experience in data collection, query or in an allied health field preferred.
Five years clinical nursing experience or experience in analyzing and interpreting processes, clinical outcomes and costs of care preferred.
Fundamental knowledge of performance improvement processes preferred.
Strong computer skills facilitating data collection and management with experience providing education/reports to groups of clinicians preferred.
Experience working at a verified and/or designated trauma center or in performance/quality management preferred.
Trauma Nurse Core Course (TNCC) and/or Trauma Care after Resuscitation (TCAR) preferred.
PHYSICAL/MENTAL REQUIREMENTS AND TYPICAL WORKING CONDITIONS:
Exposure to stressful situations, including those involving public contact, as well as, trauma, grief and death.
Able to wear personal protective equipment that includes latex materials or appropriate substitute if required for your position.
Is able to move freely about facility with or without an assisted device and must be able to perform the functions of the job as outlined in the job description.
Overall vision and hearing is necessary with or without assisted device(s).
Frequently required to sit/stand/walk for long periods of time. May require frequent postural changes such as stooping, kneeling or crouching.
Some exposure to blood borne pathogens and other potentially infectious material. Must follow MyMichigan Health bloodborne pathogen and TB testing as required.
Ability to handle multiple tasks, get along with others, work independently, regular and predictable attendance and ability to stay awake.
Overall dexterity is required including handling, reaching, grasping, fingering and feeling. May require repetition of these movements on a regular to frequent basis.
Physical Demand Level: Sedentary. Must be able to occasionally (0-33% of the workday) lift or carry 0-10 lbs.
Equivalent Experience and Other Comments (Education):
Education: BACH
Equivalent Experience: In addition to the required BSN, a Master of Science in Nursing (MSN) or masters degree in business, data analytics, health administration preferred.
Education Specialization: NRG
Essential: true
Other Comments:
Credential:ACLS: Advanced Cardiac Life Support
Equivalent Experience: Within 12 months of hire or transfer
Qualification Source:
Essential: true
Credential:BLS: Basic Life Support
Equivalent Experience: Within 3 months of hire or transfer
Qualification Source: AHA
Essential: true
Credential:RN: Registered Nurse
Equivalent Experience:
Qualification Source: MI
Essential: true
Share this job