Job Summary
To provide leadership, direction and assistance to the hospital and the medical staff to achieve the goals of the Performance Improvement (PI) Plan. Serves as a resource, educator, and consultant. Ensures accurate data collection, analysis, and reporting to establish and maintain practice standards and organization‑wide PI efforts.
Responsibilities
Screen cases to identify issues for physician review, using criteria established by the medical staff and the NYS DOH.
Initiate the peer review process by reviewing cases identified through screening (mortalities, OR incidents, infections, etc.).
Document findings in MIDAS within established time frames.
Identify cases presenting a serious concern (possible sentinel events, aberrant practice patterns, potential lawsuits, etc.) and alert department director, medical staff leadership, and claims manager.
Conduct special studies in collaboration with medical staff on high‑risk, high‑volume, or problem‑prone issues, including chart review, data collection, data analysis, and graphical display.
Review incident reports on a daily basis as part of risk management.
Initiate a more thorough review to clarify circumstances of incidents of serious concern.
Create MIDAS reports to assist in identifying patterns and trends.
Conduct comparative performance reviews of cases meeting core measure criteria and identify opportunities for improvement (OFI) to resolve with the appropriate physician and/or staff.
Initiate strategies for correction of identified OFIs and ensure physician‑related OFIs are documented in quality profiles.
Verify data integrity prior to harvest and re‑review selected medical records for errors when prompted by validation chart requests.
Achieve a score of at least 85% on validation studies.
Serve as a resource to other departments in support of their QI efforts, including analysis of data from sources such as Trae, Hospital Compare, etc., to identify patterns and areas for improvement.
Assume leadership responsibility for identified QI projects and major initiatives such as MIDAS management.
Support on‑site DOH survey reviews by coordinating information, reviewing medical records, and assisting surveyors with requests.
Serve as a member of the Quality Council and/or other hospital committees.
Perform other related duties as assigned.
Qualifications
Minimum of five years experience in Med/Surg nursing.
Minimum of two years experience in quality improvement or risk management.
Graduation from an accredited nursing school; BSN preferred.
Licensed in NYS as a Registered Professional Nurse.
Computer literacy, including word processing and data management.
Excellent oral and written communication skills.
Excellent interpersonal skills; ability to work effectively with individuals and groups.
Initiative, creativity, and flexibility.
Knowledge of universal precautions, personal protective equipment, and infection control policies.