Quality Data Analyst

ST. CHARLES HEALTH SYSTEM

JOB DESCRIPTION

TITLE:                                     Quality Data Analyst           

REPORTS TO POSITION:     Manager, Quality

DEPARTMENT:                      Quality Management

DATE LAST REVIEWED:       January 14, 2026

OUR VISION:                           Creating America’s healthiest community, together

OUR MISSION:                         In the spirit of love and compassion, better health, better care, better value

OUR VALUES:                         Accountability, Caring, Teamwork and Safety

DEPARTMENT SUMMARY: The Quality Management (QM) department provides essential services to St. Charles Health System (SCHS) including: quality improvement expertise and support; data analysis & abstraction; regulatory affairs, accreditation and licensing expertise and support; policy and document library management and support.

POSITION OVERVIEW: The Quality Data Analyst (QDA) applies analytics to support SCHS strategic priorities and drive Quality System Key Performance Indicators (KPIs). Working with a broad group of cross-functional teams, the QDA supports data analysis, goal and target setting, and KPI performance improvement. Responsibilities include sourcing, compiling, analyzing, and validating quality data; preparing internal and external reports; and providing technical support and oversight for routine statistical reporting and ad hoc analyses as directed by the Quality Manager. The QDA collaborates closely with teams including Caregiver Safety, Regulatory, Infection Prevention, Business Intelligence, Epic and Clinical Informatics, Finance, Lean Improvement, HRIS, Clinical Documentation Integrity, Patient Safety & Risk, Patient Experience, and Medical Staff to advance KPI outcomes using the SCHS Data Strategy. This position does not directly manage other caregivers.

ESSENTIAL FUNCTIONS AND DUTIES:

Provides support in the development and maintenance of guidelines, standards, methodologies, and conventions for Quality Improvement reporting deliverables. Ensures complete and accurate logical definition of Quality Improvement data. Responsible for validation and maintenance of data integrity. Ensures that the metrics being reported accurately reflect process measures such as bundle compliance.

Queries, cleans, and aggregates data from a variety of internal and external sources.

Solves complex analytical problems using quantitative approaches with unique blends of analytical, mathematical, and technical skills.

Serves as the lead for Quality Improvement of data requests and reporting.

Ensures that Quality Improvement data is valid and accurate. Provides documentation and training materials to transfer knowledge of operational support workflow to the Quality Outcomes Nurse.

Retrieves and analyzes data from NHSN (National Healthcare Safety Network), PureOHS, Premier (benchmarking), Control Check, Knowledge Portal, Joint Commission, Lumere, Strata, Safety Alert System and Power BI. Builds and maintains dashboards using Power Business Intelligence (BI) to Capture (multiple data sources including excel, forms), Build (Transform & Model) and Report (Visualize and Share), including data pipeline standards. Cleans data using Power query (ETL engine) to Extract (connect to data), Transform (clean and shape), and Load (send to data model).

Performs Data Modeling for relationships and how tables connect and reporting on how data is visualized using design principles and digestible visual components.  

Understands and navigates Epic reporting tools such as Slicer Dicer, Workbench Reports, Dashboards, and Components.

Works in collaboration with data abstractors for CMS Core Measures, Nurse Sensitive Indicator Reporting (NDNQI), and Surgical Databases such as NSQIP (National Surgical Quality Improvement Program).

Remains knowledgeable and able to navigate Premier database (Quality Advisor, Pay for Performance (Hospital Value Based Performance, Hospital Readmission Reduction Program, Hospital Acquired Condition Reduction Program), Premier Analytics, Quality Console) for Quality benchmarking and reporting. Creates reports and dashboards to share data and benchmarking analyses with the organization.

Assesses the reporting needs of various stakeholders through investigation, analysis, and evaluation to generate reporting specifications.

Receives formal requests from end-users (data intake form), including report specifications, and ensures reporting requests are completed (standard metric definition information tool).

Collaborates with Business Intelligence Developers (BID) and Cogito Business Analysts (CBA). Establishes a prioritization process for transparency to stakeholders regarding timelines for data requests.

Supports the Quality Outcomes Nurse in the Key Performance Indicators including collaboration with department leaders, and shared practice councils to drive clinical excellence and quality outcomes

Maintains the central repository SharePoint site for Registry Data, including performance data, to drive improvement efforts and alignment to system Key Performance Indicators.

Serves as the quality lead for Data Governance in collaboration with Information Technology (IT).

Supports Regulatory Readiness Tracer compliance and outcomes.

Analyzes data for trends and facilitates notification to appropriate individuals. Shares the summary of trends for “telling the story” with data. Applies complex mathematical concepts and statistical methods to plan and design deliverables, as well as interpret data.

Supports the vision, mission, and values of the organization in all respects.

Partners with the Lean Improvement Office on a variety of process improvement initiatives as indicated by project type and scope.

Functions as a “champion of change” and consistently leads with humble inquiry to unearth quality gaps, lead clinical improvement initiatives, create sustainment plans and monitor for variation.

Provides and maintains a safe environment for caregivers, patients, and guests.

Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.

Deliver’s customer service and/or patient care in a manner that promotes goodwill, is timely, efficient and accurate.

May perform additional duties of similar complexity within the organization, as required or assigned.

EDUCATION:

Required: Bachelor’s degree in statistics and Business Analytics, Computer Science, or other quantitative-oriented field or four (4) years of related work experience may be considered.

Preferred: Master’s degree in public health, business administration and healthcare                      

LICENSURE/CERTIFICATION/REGISTRATION:

Required: Three (3) years of experience in a position using analytics. Experience with Power BI including Power Query. Valid Oregon driver’s license and ability to meet St. Charles Health System driving requirements. Ability to travel to business functions/trainings/meetings and all SCHS worksites. Certified Professional of Healthcare Quality (CPHQ) within one year of hire.

Preferred: N/A 

EXPERIENCE:

Required: Three (3) years’ experience in a position related to analytics, reporting and/or performance improvement.

Preferred: Experience with data governance and BI concepts in healthcare industry. Experience with national healthcare quality metrics, such as electronic clinical quality measures (eCQMs). Experience with principles and methods of continuous quality improvement and LEAN. Experience using standard project management techniques. Experience participating in multi-disciplinary workgroups.

ADDITIONAL POSITION INFORMATION:

Must have:

Advanced proficiency in Microsoft applications (Word, Excel and Power BI), document preparation.
Applied statistical skills such as distributions, statistical testing, regression, etc.

Strong communication skills.

Strong critical thinking skills.           

Must be able to:

Create simple to complex data exhibits using a variety of analytical tools (Pivot tables, formulas).

PERSONAL PROTECTIVE EQUIPMENT: Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely.

PHYSICAL REQUIREMENTS: 

Continually (75% or more): Use of clear and audible speaking voice and the ability to hear normal speech level.  

Frequently (50%): Sitting, standing, walking, lifting 1-10 pounds, keyboard operation. 

Occasionally (25%): Bending, climbing stairs, reaching overhead, carrying/pushing or pulling 1-10 pounds, grasping/squeezing.  

Rarely (10%):  Stooping/kneeling/crouching, lifting, carrying, pushing or pulling 11-25 pounds, operation of a motor vehicle. 

Never (0%):  Climbing ladder/step-stool, lifting/carrying/pushing or pulling 25-50 pounds, ability to hear whispered speech level. 

Exposure to Elemental Factors 

Never (0%):  Heat, cold, wet/slippery area, noise, dust, vibration, chemical solution, uneven surface. 

Blood-Borne Pathogen (BBP) Exposure Category 

No Risk for Exposure to BBP 

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