Description

JOB PURPOSE:
Surveilling and analyzing performance data for special cause variation and improvement opportunities. Ensuring all performance improvement activities are in compliance with regulatory and accreditation bodies. Performs work in abstracting, quality control and submission of performance data for quality initiatives and other performance improvement activities for the system. Supports an efficient and timely peer review process through chart review and data collection.

KEY RESPONSIBILITIES:
1. Abstracts clinical data from the Medical Record for various Quality databases using pre-existing criteria.
2. Inputs data electronically for submission to Quality organizations and Core Measures within established timeframes.
3. Maintains integrity and security of all information and data within the scope of the position with strict confidentiality.
4. Assists in establishing quality strategic outcomes and internal/external benchmarking initiatives for Piedmont Hospital/Core Measures.
5. Conducts clinical chart review for quality measures as assigned.
6. Develops and implements data collection tools to drive compliance and a timely reporting process.
7. Monitors and analyzes data, identifies trends and risk related issues and reports recommendations.
8. Provides staff and physician interventions as appropriate, incorporating process improvement tools.
9. Provides guidance for the implementation of Evidence Based Medicine in quality initiatives and/or throughout the pathway program.
10. Coordinates peer review process for medical staff, to include ongoing professional performance evaluations and reappointment profile data.
11. Performs surveillance activities for quality, safety, accreditation and infections for PHC Inpatient and Outpatient services.
12. Reports notifiable diseases to proper authorities.
13. Directs entry of essential infection control data into various electronic medical records and data bases.
14. Participates in the Internal Audits conducted by the Surveillance and Analysis Team.
15. 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