POSITION SUMMARY

Conducts quality assurance compliance audits, reviews policies and procedures. Responsible for training new employees or existing employees, and implementing changes in work behavior or tactics. QI Coordinator monitors and manages projects that directly impact the facility's performance while capturing metrics, statistics or data from personnel or work outcome.

Principal Duties:

1. Supports systems designed to promote hospital-wide performance improvement. Via Review of Medical Record for issues related to quality and performance

a. Performs concurrent and retrospective review of core measure patients and/or quality indicators in compliance with National Hospital Inpatient Quality Measures, Vermont Oxford Network and regulatory agencies such as Joint Commission, CMS, HQID project, MIEMSS, DHMH, HSCRC, etc.

b. Knowledgeable about core measures, Vermont Oxford Network Data, etc., informing director of changes in protocol/data requirements and implications for clinical practice

c. Participates in the education of medical staff, employees, leadership and Board on quality and performance indicators selected by the organization as well as the requirements and implications of these measures for clinical practice

d. Performs retrospective and concurrent review of specific focused studies (including procedures, diagnosis and other studies) requested by medical staff, hospital departments and committees

e. Flags and documents variances for selected indicators and variables for focused studies and implements indicators for medical staff and peer review including OPPE and FPPE as required by TJC

f. Participates in data extraction for submission of required data electronically to Vermont Oxford, MIEMSS, NAS Collaborative and DHMH. Facilitates the organization's responses in order to meet established time frames for submission

g. Collects, interprets and reports data at specified intervals with accuracy and completeness h. Demonstrates proficiency in abstraction and interpretation of data reports

2. Interpretation of Clinical Data

a. Identifies and interprets objective and subjective data found in the medical records

b. Compares the identified data to established criteria to determine appropriateness of care

c. Abstracts and reports PI information in appropriate format to detect patterns and/or problems in the delivery of care

d. Identifies potential areas for change and improvement of the study design and data collection and makes recommendations

e. Develops new ongoing quality projects and evaluates the appropriateness of indicators and criteria for quality monitoring

3. Development and maintenance of knowledge including Committee, Collaborative and Team Support

a. Maintains current knowledge of PI strategies, principles, methodologies, techniques and data analysis.

b. Maintains current knowledge of TJC, CMS, national quality indicator guidelines, Magnet, NANN, AWHONN, NAN and NDNQI and assesses compliance for assigned areas.

c. Works with Leaders, Chiefs, Vice Chiefs and NICU specific as well as facility Committee Chairs to organize and accomplish goals of required committee meetings, collaboratives and teams

d. Executes effective improvement projects through multidisciplinary team collaboration

e. Active participant in NICU committee/council meetings and proactively provides reports and information as required by the committee or team and meets 90% attendance

f. Assures that issues are communicated to appropriate committees or individuals and that issues have timely resolution

g. Maintains peer review information in strict confidentiality and assures entry into database and PI file

h. Coordinates assigned meetings, assisting with agenda and providing all data metrics from various committees.

4. Provides continued improvement consulting services to customers

a. Evaluates referrals to the Quality Department. Refers issues to appropriate department Risk Management, Infection Control and Pharmacy. Follow up as needed.

b. Maintains confidentiality of QA material

c. Participates in CQI teams to improve organizational performance such as FMEA, RCA.

Customer Service:

1. Greets customers in courteous, friendly, respectful and professional manner at all times, including maintaining eye contact when appropriate.

2. Follows communication protocols to both internal and external customers, including introducing him/herself with job title and experience, asking open ended questions, such as "How may I be of help to you?" using the customer's name as soon as it is learned.

3. Responds promptly and appropriately to customer questions/concerns/complaints and attempts immediate resolution.

4. Keeps customer's information confidential, including public places such as elevators or the cafeteria.

5. Provides assistance and offers help immediately, including finding someone else to meet the request, if unable to do so him/herself. Introduce other staff to customers when a hand-off occurs and explain that the person will provide excellent service.

6. Demonstrates commitment to excellent service recovery when a customer's expectations have not been met.

Commitment to Co-Workers:

1. Offers assistance to colleagues and other departments when needed.

2. Takes responsibility for solving problems regardless of origin; completes assignments, and respects deadlines.

3. Resolves conflict directly with colleagues and seeks assistance from others if the issue cannot be resolved. Refrains from criticism in public.

4. Mindful and respectful of others' time and schedules. Attends meetings on time and communicates any absences.

5. Provides co-workers with a status report for continuity of workflow when planning to be out of the office, off the unit, or away from the department

Communication Etiquette:

1. Respectful, courteous and professional in all forms of communication and follows facility's service communication protocol in all interactions.

2. Refrains from use of personal cell phone in patient care areas and keeps usage to a minimum at all other times while on duty.

3. Does not text or use e-mail during meetings (except for exigent or emergency situations).

4. Limits use of business cell phone during meetings (remain on vibrate and/or calls go to voicemail).

5. Makes every effort to answer telephone calls within three rings, introducing him/herself, department and title (if appropriate). Asks permission before placing the caller on hold or using the speakerphone. If caller is transferred, gives the caller the extension number of the person he or she is being transferred to. Offers further assistance to the caller upon completing the conversation.

6. Maintains an appropriate voicemail message and when away from the office has an out-of-office email message that is brief, current, and includes name and department and offers the caller options if possible.

7. Returns email and voicemail messages promptly but no later than within one business day (24 hours).

8. Always mindful of voice and language in public.

Self Management:

1. Reports to work appropriately groomed and in compliance with the Hospital's dress code. Wears identification badge at all times at chest level and facing outwards so identification is clearly visible.

2. Complete all assignments within deadlines or negotiates alternative actions and time frames in order to achieve desired outcomes.

3. Completes mandatory, annual education and competency requirements.

4. Follows UMCAP safety, infection control and employee health standards.

5. Demonstrates responsibility for personal growth, development and professional knowledge and competency.

6. Adhere to all UMCAP and department policies and procedures, including Code of Conduct and professional behavior standards. Does not exceed Hospital guidelines in reference to attendance, punctuality, and use of sick and unplanned absences. Provides notification of absences, lateness and vacation requests according to department guidelines. Respects length of time for lunch and break times.

7. Reviews, signs, and adheres to UMCAP and/or departmental confidentiality statement.