Description

JOB PURPOSE:

The Sr Quality Safety Specialist at Piedmont Augusta Supports the medical staff Quality Department review processes for Piedmont Augusta hospitals. You will work closely with the CMO and Medical staff leaders to advance quality of care for Augusta Providers. The position is autonomous and reports to Quality and Safety Leadership. The position uses clinical background and nursing expertise to support improving patient safety, reducing patient harm, and improving patient outcomes through our peer review process.

Specializes in bringing change to the organization through surveillance and analysis of clinical and operational processes. Performs systematic review of complex processes related to Piedmont’s Quality Management Program including multidisciplinary professional practice evaluation, root cause analysis, internal audit, policy management and infection prevention. Understands and interprets changes in regulation, value based purchasing programs, accreditation and publically reported data. Drives quality improvement through collection and timely dissemination of reliable information related to quality, safety and service.

KEY RESPONSIBILITIES:
1. Performs surveillance activities for quality, safety, accreditation and infections for PHC inpatient and outpatient services.
2. Supports Quality Management Programs including: Always Safe, RCA, PPE, error prevention, performance reliability and Piedmont’s ‘Safety Coach Program’.
3. Performs quality and safety training for new and existing staff
4. Provides expert support in data analytics (e.g. statistical process control, regression analysis, correlational studies); report writing and development of stakeholder presentations.
5. Maintains knowledge of current and new reporting requirements for external organizations/programs (e.g. CMS, AHRQ, DNV, State, Leapfrog, VBP, CDC, quality registries, etc.)
6. Supports multiple hospitals in understanding regulatory, reporting and accreditation changes and their impact on hospital operations.
7. Maintains expert knowledge of existing and new quality measures, definitions, targets and benchmarks
8. Abstracts clinical data from the Medical Record for various Quality databases using pre-existing criteria.
9. Inputs data electronically for submission to Quality organizations and Core Measures within established timeframes.
10. Collaborates with IT experts and process engineers to translate regulatory requirements into system specifications
11. Maintains integrity and security of all information and data within the scope of the position with strict confidentiality.
12. Conducts clinical chart review for quality measures as assigned.
13. Provides staff and physician interventions as appropriate, incorporating process improvement tools.
14. Provides guidance for the implementation of Evidence Based Medicine in quality initiatives and/or throughout the pathway program.
15. Coordinates peer review process for medical staff, to include ongoing professional performance evaluations and reappointment profile data.
16. Directs entry of essential infection control data into various electronic medical records and data bases.
17. Participates in the Internal Audits conducted by the Surveillance and Analysis Team.
18. Assists with special projects.
KNOWLEDGE, SKILLS, ABILITIES
General knowledge of infections
Ability to work independently with minimal supervision, as well as, in a collaborative, team environment
Ability to handle multiple priorities and deadlines
Knowledge of principles of quality outcomes, statistical data analysis and performance improvement process.
Skill and ability in Microsoft Office applications
Advanced knowledge of spreadsheet and database software
Current knowledge of accreditation and other pertinent regulatory standards.
Training or background in computer, data management, and statistics