Requisition Number: QUALI02232
Position Summary: Under the direction of the Director of Quality Management, oversees various quality-related initiatives within the organization, which may include but is not limited to activities related to continuous quality improvement within the health system. May also provide support to other members of the Process Improvement Department team (Quality Managers) as needed.
- Managing the maintenance, distribution, and analysis of all quality indicator dashboards organization-wide
- Serving as the organization's ISO Quality Management system backup management representative, to include the performance of internal audits and all related recordkeeping
- Serve as an ISO internal auditor for non-clinical processes (training will be provided)
- Participation as an improvement advisor on internal quality improvement committees, to include a focus on data collection, aggregation, display, and interpretation
- Performing medical record audits for quality-related or risk management-related issues, to include datamining, aggregation of results, determination of optimal methods of displaying quality data, and communication of results on a regular basis to stakeholders.
- Processing of all organizational administrative policies, to include working closely with members of the organization's management team (including senior leadership) to ensure timely review and approval of policies, any ongoing and necessary revisions, creation of new policies, and posting finalized policies to the hospital policy Portal.
- Processing and distributing various internal quality reports using the MIDAS+ system. This includes some data entry requirements.
- Performs ongoing statistical analysis of quality data to identify patterns and trends that may be targeted for improvement. Work closely with members of the hospital's administrative team on analyzing and understanding this data and serve as an improvement advisor as necessary.
- Maintain physician quality indicator profiles and distribute results on a quarterly basis (Ongoing Professional Practice Evaluation)
- Provide support to department directors with external database reporting of hospital quality measures
- Serve as backup liaison to the Director of Quality Management for regulatory survey activities (CMS/Joint Commission/DNV/ODH), to include direct participation in regulatory/accreditation surveys by serving as an escort/guide for surveyors, internal tracer audits, and responding to internal questions/queries on standards interpretation. Experience with Joint Commission, DNV, CMS, and ODH survey activities is desired.
- Serve as one of the department's MIDAS+ system administrators to include assisting users with system access, database assembly, report writing and other needs as they arise
- Perform other duties as requested
- Exceptional computer skills are REQUIRED. Extensive experience with Microsoft Excel, Word, and PowerPoint is strongly preferred. Candidate must be able to create various types of graphics within Excel using quality data, and present these graphics in a professional and polished manner.
- Strong verbal and written communication skills. Must be able to interact professionally with all levels of staff and leaders within the organization, up to and including co-workers, senior leaders (Vice Presidents) and members of the physician staff.
- Strong interpersonal skills and an ability to work with others effectively, cordially, professionally and tactfully. This is a “high visibility“ position within the health system and candidates must be comfortable in effectively interacting with all members of the organization's management team.
- Excellent critical thinking ability, to enable the candidate to think abstractly and make appropriate decisions when managing the workload.
- Highly detail-oriented candidates will have the strongest consideration. Must be able to turn out error-free work product on a regular and consistent basis.
- Ability to work independently at a fast pace, to include an ability to quickly adapt to changes in priorities on a day-to-day, if not an hour-to-hour basis.
- Ability to meet strict deadlines.
- An honest, dependable and trustworthy attitude is required, with a capability for dealing with sensitive information in a confidential manner at all times.
- Healthcare quality is a very rapidly changing environment. Top candidates will have an ability to learn new tasks quickly, be willing to learn tasks/responsibilities as needs arise and integrate them into existing workflows.
- Ability to operate telephones, printers, copier, and fax machine.
- Familiarity with LMH organizational structure is a plus.
- Experience with MIDAS+ is a strong plus.
Licking Memorial Health Systems is an equal opportunity employer and maintains compliance with all state, federal, and local regulations. Licking Memorial Health Systems does not discriminate against applicants because of race, religion, color, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, family medical history or genetic information, political affiliation, military service, or other non-merit based factors protected by law.