Rn Quality Improvement Analyst-Surgical Services (Full Time Days)

ST. CHARLES HEALTH SYSTEM

JOB DESCRIPTION

TITLE: RN Quality Improvement Analyst

REPORTS TO POSITION: Director - Perioperative Services

DEPARTMENT: Perioperative/Perianesthesia Services

DATE LAST REVIEWED: November 29, 2023

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; regulatory affairs, accreditation and licensing expertise and support; environment of care safety programming, expertise, and support; emergency preparedness; policy and document library management and support; data abstraction; integrity of clinical documentation; the patient experience and grievance program; and risk management and patient safety program.

POSITION OVERVIEW: The RN Quality Improvement Analyst at St. Charles Health System (SCHS) provides analytics to drive key success metrics and facilitates Quality Improvement initiatives within their assigned service lines and committees in alignment with the organization’s True North objectives. This position works collaboratively with a diverse array of stakeholders, and will take lead on program and initiatives, to assist with data analysis, goal selection, process improvement, and the development of sustainment plans. This position is responsible for sourcing, collating, analyzing and validating quality data, preparing reports for internal purposes and external reporting which includes technical support for and oversight over routine statistical reports and ad hoc analyses. The RN Quality Improvement Analyst works in close partnership with the Quality Management and Safety teams to meet regulatory and accreditation requirements, as well as the Lean Improvement Office to ensure that all work is approached with a Lean mindset. This position does not directly manage other caregivers, however, may be asked to review and provide feedback on the work of other caregivers.

ESSENTIAL FUNCTIONS AND DUTIES:

Utilizes Quality Improvement principles, such as PDSA and A3 thinking, to design, develop, implement, and sustain True North initiatives for their respective service lines and committees.

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, maintenance of data integrity and the ongoing quality control of Quality Improvement deliverables.

Works collaboratively with a diverse array of caregivers, leadership, and support services to assist with data collection, analysis, goal selection and the development of various auditing tools, such as: standard work, Epic bundles, and performance scorecards.

Ensures Quality Improvement data is valid and accurate while providing documentation and training materials to transfer knowledge of operational support workflow to others upon request.

Participates in development and maintenance of numerous quality and safety dashboards and scorecards for their respective service lines and committees. Queries, cleans, and aggregates data from a variety of internal and external sources using SQL and/or other query languages and methods.

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

Retrieves and analyzes data from NHSN (National Healthcare Safety Network) and reporting platforms such as PowerBI, Crystal Reports, Epic Cogito reporting tools, CMS Core Measures, nursing and surgical databases such as NDNQI (National Database of Quality Indicators) and NSQIP (National Surgical Quality Improvement Program) and Value-Based Care contracts and incentive programs. Creates reports and dashboards to share data and analyses to with the organization.

Analyze, develop, test, implement and maintain reporting user interfaces and dashboards.

Assess the reporting needs of various stakeholders through investigation, analysis, and evaluation to generate reporting specifications. Receive and document formal requests from end-users, including report specifications, and ensure reporting requests are completed.

Leads system data reporting programs (i.e. Leapfrog) and system initiatives (i.e. Mobility is Medicine, Continuous Glucose Monitoring).

Prepares detailed specifications as well as technical and user documentation from which reports, downloads, and extracts will be written.

Analyzes data for trends and facilitates notification to appropriate individuals as warranted. Applies complex mathematical concepts and statistical methods to plan and design deliverables, as wells as interpret data.

Coordinates and supports department level Safety and Quality Committee (SQC) meetings and the reports to hospital level SSQC.

Supports continuous survey readiness in coordination with Accreditation Manager including regular rounding, mock (and actual) survey participation, CAREboard support, and auditing.

Supports our Patient and Safety Risk Management team with data analysis and projects that align to goals of our patient safety and risk program.

Completes quality and patient safety reports as needed, including analysis of data, identification of trends, and recommendations for improvement.

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

Supports the Lean Improvement Office by functioning as a “champion of change” and consistently leading with humble inquiry to unearth quality gaps, lead 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.

Delivers 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, or Associate’s degree plus two (2) years’ experience in healthcare field, data analytics, public health, or other closely related field

Preferred: Master’s degree in public health, healthcare management, data analytics, statistics.

LICENSURE/CERTIFICATION/REGISTRATION:

Required: Current Oregon RN license. Minimum of one Epic Data Model Certification or ability to gain certification within 6 months of hire. Certified Professional of Healthcare Quality (CPHQ) within 1 year of hire. Ability to travel to business functions/trainings/meetings and all SCHS worksites.

EXPERIENCE:

Required: Five (5) years experience in health care, public health, or a related field. Advanced proficiency in Microsoft applications (Word, Excel and Access), database management, document preparation and other visual forms of data analysis required. Ability to create simple to complex data exhibits using a variety of analytical tools. Applied statistics skills such as distributions, statistical testing, regression, etc. Strong communication skills. Critical thinking and an analytical mind.

Preferred: Ten (10) years’ experience in Healthcare, facilitating Quality Improvement initiatives using Lean or other process improvement framework. Experience in statistical analysis environments such as R, MATLAB, SPSS, Insight SAS or related product. Experience with Joint Commission standards and other standards such as CMS and OSHA. Experience facilitating groups through complex and sensitive issues and teaching process improvement principles. Experience working with medical staff on performance improvement.

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 11-15 pounds, operation of a motor vehicle.

Never (0%): Climbing ladder/stepstool, 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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