Quality Improvement Coordinator

SUMMARY:Under the direct supervision of the Department of Emergency Medicine's Director of Quality and Patient Safety and under the general supervision of the Physician-In-Chief of Emergency Medicine performs daily collection review and analysis of patient data to determine quality of patient care delivered in emergency medicine. Assists in developing guidelines criteria and clinical indicators to measure quality of care. Ensures compliance to standards of Hospital quality assurance program The Joint Commission (TJC) and other regulatory agencies.

PRIMARY DUTIES AND RESPONSIBILITIES:

In conjunction with members of the Quality Assurance department ensures emergency department procedures and documentation meet or exceed Hospital quality assurance standards and TJC standards to ensure continued accreditation. Participates in the recommendation development and implementation of effective screens and/or clinical indicators from multiple data sources to measure the quality of medical services provided within the department.

Identifies scope and nature of appropriate patient population to be studied. Monitors application of screens and indicators to evaluate their appropriateness. Recommends appropriate follow up and corrective action where necessary to physician or committee responsible for peer evaluation. Resolves delays in implementation of actions as appropriate. Provides guidance and interpretation to physicians nurses and others of the Hospital assurance standards and the criteria as established by TJC and other regulatory agencies.

Performs daily analysis of medical records for patients seen on previous day to identify clinical indicators of patient care. Evaluates performance compliance to Hospital*s quality assurance standards. Retrieves or arranges for production of data on indications for procedures drug usage evaluation and medical records review. Monitors aspects of physician and nurse documentation in medical record; recommends changes to ensure consistency and efficiency of documentation.

Monitors and tracks documentation and clinical performance by individual personnel having responsibility for medical record documentation to identify compliance to standards and to identify non-compliance trends. Provides guidance to residents nurses and attending physicians in the emergency department on reviewed aspects of documentation and patient care identifying areas needing improvement and suggesting appropriate corrective action to ensure compliance to standards. Follows up to assess level of compliance.

Performs daily review of diagnostic tests performed in the ED during the previous 24-hour period to determine concordance of readings and interpretations. Directly notifies patients of many abnormal results and discrepancies. Where abnormal results are more complex or require the judgment of a provider coordinates patient outreach and follow-up with the responsible physician or APP.

Coordinates telephone follow-up calls by physician or other clinician to selected patients. Reports clinically relevant abnormal findings to patient primary care physicians and assists in reporting to state and federal health departments as required by relevant regulations and laws.

Participates in regular meetings among ED quality staff to review cases and lessons learned. Engages in continuous improvement of group policies and procedures.

Compiles analyzes and maintains emergency medicine quality assurance data and files. Maintains master emergency medicine quality assurance record of meeting minutes. Develops and maintains related computerized data bases; performs statistical analyses and presents results in table and graphic formats as requested. Compiles and distributes periodic reports on quality assurance indicators and data. Assists in trending selected indicators for focused review.

Maintains current knowledge of quality assurance issues concepts and topics and of changes in applicable federal state and voluntary regulatory standards that related to quality assurance and TJC accreditation through reading pertinent literature and participating in various internal and external committees as appropriate.

Conducts periodic special studies and projects related to emergency medicine quality assurance.

REQUIRED QUALIFICATIONS:

Licensure as Registered Nurse in the State of Rhode Island by the Rhode Island Board of Nursing or licensure as a Registered Nurse in accordance with the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing.

RN nursing degree is required.

At least three years progressively more responsible experience in a health care position with demonstrated familiarity with clinical systems and indicators quality assurance methods and standards and ability to review and interpret information contained within the medical records.

Analytical skills to identify and assess problems activities and causes related to provision of clinical care and methods of quality assessment and to effectively prioritize and carry out quality assurance activities.

Knowledge of federal state and voluntary quality assurance regulation and standardsin order toassess compliance to standards.

Clinical-based knowledge of physician and nursing care and general medical care to effectively review records and patient information to apply clinical knowledge and experience to analyze findings relative to quality assurance criteria and to report summaries patterns and trends of data.

Ability to operate personal computer to develop and maintain data bases and to perform computer-assisted statistical analyses.

Interpersonal skills to effectively interact with patients and health care providers in the collection interpretation and reporting of data.

Demonstrated knowledge and skills necessary to provide care patients with consideration of aging processes human development stages and cultural patterns in each step of the care process.

WORK ENVIRONMENT AND PHYSICAL REQUIREMENTS:

Normal office environment with some exposure to patient care areas as needed to review documentation or confer with others. Remote work is allowed at the discretion of the Director of Quality and Patient Safety.

SUPERVISORY RESPONSIBILITY:

None