Michigan Trauma Quality Improvement Program (MTQIP) Reviewer Responsibilities:
Work closely with the Trauma Program Staff, including registrar, physicians, clinical staff and program manager to develop and implement standard practices, policies and procedures that support efficient capture of data.
Will be required to identify clinical quality improvement opportunities, participate in other special projects as requested by the coordinating center, resolve data discrepancies, and actively participate in site audits.
Attend MTQIP, Trauma program meetings as required. Attendance at Clinical Quality department meetings and Quality and Patient Safety planning meetings required.
Will be required to enter high quality data into applicable databases, as well as participate in rounds on Trauma patients, and participate in Clinical Quality department meetings as appropriate.
Works under the supervision of the Trauma Program Manager AND the Clinical Quality Department Manager.
Will be expected to learn trauma coding to ensure complete data abstraction of trauma cases.
1. Supports the Mission, Vision and Values of Munson Healthcare.
2. Embraces and supports the Performance Improvement philosophy of Munson Healthcare.
3. Promotes personal and patient safety.
4. Uses effective customer service/interpersonal skills at all times.
5. Is authorized to provide individual case review, and aggregate data, by the Board, Vice President Legal Affairs, Vice President Medical Affairs, and all peer review/quality improvement committees.
6. Promotes use of risk reduction strategies. Serves as a role model for quality and patient safety throughout the organization. Works with multidisciplinary teams to identify and investigate patient care quality/safety issues, events, or trends; recommends prevention strategies to improve healthcare delivery using process improvement techniques (e.g., root cause analysis, control and run charts, value stream mapping).
a) Notifies direct supervisor of infractions of policy, procedure, laws and regulations as they are identified.
b) Notifies Accreditation Resources and/or Corporate Compliance Officer of any issues that continue to be unresolved.
7. Maintains knowledge of current PI methodologies and clinical informatics through regular review of literature, conference attendance, participation in professional organizations, etc.
a) Analyzes, interprets and synthesizes relevant literature and research studies to maintain knowledge of updated and current practices in specific area of interest.
b) Provides customers with up to date information relevant to Clinical Quality and specific area of responsibility.
c) Understands concepts of Six Sigma/Lean principles and tools.
d) Maintains baseline knowledge of Joint Commission standards, National Patient Safety Goals, and other regulatory requirements impacting matters within the assigned scope of responsibility; ensures that these factors are considered and integrated into PI activities.
e) Expected to maintain professional growth and development. Demonstrates an ongoing commitment to learn.
8. Develops, designs, and maintains relevant electronic data systems (i.e. clinical data systems that support facility information needs for the purpose of performance improvement and assessment of clinical quality/patient safety).
a) Assists in design, installation, implementation and evaluation of existing or new database applications, tables and files.
b) Oversees the performance of day-to-day operation and maintenance of software systems to include updates of the system as indicated, including periodic testing of integrity of the systems/data.
c) Recommends improvements to the systems as needed.
9. Comprehends data, trends, and measurement outcomes. Communicates complicated concepts in a clear and understandable manner to health care professionals both verbally and in written form. Able to present to individual providers as well as groups, both internal and external as requested.
a) Manages data maintaining high standards for accuracy and assuring data integrity.
b) Develops and implements data collection processes: provides research, benchmarking, analysis and summary
c) Assists in the development of outcome assessment tools for the continuum of care. Responsible for analyzing and reporting patient care outcomes data from various databases and identifying plans for improving outcomes, and resource utilization.
d) Conducts thorough analysis of patient care and outcomes through medical record abstraction and review.
e) Interprets abstracted information to develop reports. Produces analysis and trending reports that include graphic presentations and statistical summaries for use by management, and/or clinical staff as well as appropriate facility, system, and external customers in accordance with established timelines. Composes grammatically correct and technically accurate case review summaries and reports.
f) Provides patient outcomes information and physician-specific outcomes data for medical staff performance improvement when requested.
g) Provides periodic data quality reports for external customers as required.
h) Validates data analysis generated internally and externally for reasonableness and accuracy, using knowledge and experience.
i) Coordinates and participates in periodic audit by external review agencies and data registry personnel.
10. Identifies processes, outcomes and trends where improvements could be made and proposes recommendations.
a) Collaborates with medical staff, nursing, and ancillary services in the application of continuous performance improvement principles, standards and tools.
b) Facilitates application of problem-solving methodologies, emphasizing the effectiveness and efficiency of evidence-based and data-based decision-making in performance improvement activities.
c) Establishes standards and procedures for projects such as tracking, reporting, recordkeeping and documentation; monitors progress on key quality initiatives and indicators, leading towards achievement of department, service line, and organizational goals. Keeps appropriate parties apprised of overall progress and monitors project results for significant deviations; proposes alternative actions to ensure that timelines and deliverables are met; reviews project deliverables to ensure they meet standards and objectives.
d) Assists in the development and revision of critical pathways and trending of variances as appropriate.
11. Serves as a resource to colleagues throughout the medical center.
a) Collaborates with leadership to identify and discuss performance improvement
strategies and opportunities as they relate to organizational mission, vision, and values, clinical outcomes, and patient safety goals.
b) Analyzes and assesses clinical practices for opportunities to improve healthcare delivery. Gains consensus as to performance improvement projects to be undertaken; assists in the development and evaluation of standards, procedures, processes, and automated tools that support established goals and regulatory requirements.
c) Serves on hospital, professional, and community committees as appropriate; provides ongoing consultation and education for hospital policies, procedures and PI/Patient Safety programs/activities designed to meet regulatory and accrediting agency requirements (i.e. Joint Commission, CMS, IHI, DHHS, and Peer Review organizations).
d) Serves as representative of CQ Department at Medical Staff and hospital committees as assigned.
e) Assists in identification of educational needs of medical and nursing staff through
participation in data registries and subsequent outcome analysis. Communicates identified educational needs to CME Coordinator and Staff Development personnel.
f) Assists in development and/or presentation of continuing education related to specific area of interest/responsibility.
12. Supports physician sections/departments and peer review activities.
a) Assists the Trauma Program Manager with identifying cases to be discussed
at the Trauma PIPS meeting monthly.
b) Coordinates and attends multi-disciplinary peer review meetings: tracking attendance, writing meeting minutes and submitting an annual report
c) Meets with Trauma Program Medical Director and Trauma Program Manager in support of medical staff performance improvement activities on a regular basis.
d) Serves as liaison between Chairperson of Peer Review Committee/Medical Department Quality Officers and the Medical Director of Quality.
e) Assures confidentiality and integrity of all medical department performance improvement and peer review activities.
13. Acts as a resource for Administrative/Departmental requests in the absence of the Manager of the Trauma Program.
14. Performs other duties and responsibilities as assigned.
Graduate of an accredited School of Nursing and currently registered and in good standing with the State of Michigan.
Completed BA or BS degree in healthcare or business related field required. BSN preferred. For those hired into an RN position after January 1, 2015, it is required to obtain a BSN within 5 years of start date.
Minimum five years of experience including clinical nursing experience in an acute care setting required; trauma experience preferred.
Must demonstrate competency and comprehensive knowledge of disease etiology, treatment and outcome management in the specific area of responsibility.
Demonstrated critical thinking and leadership in process improvement and project management preferred.
Possesses knowledge of the clinical capabilities of Munson Medical Center as well as knowledge of hospital organization and department functions.
Excellent written and verbal communication/interpersonal skills and a positive customer relations philosophy.
Previous clinical chart review and abstraction experience and/or experience analyzing and interpreting processes of care and clinical outcomes preferred.
Ability to proficiently create and utilize databases, word-processing, spreadsheets, presentation programs and other software relevant to the job. Requires technical knowledge of hospital applications data-query software spreadsheets and report-generating software. Internet skills and literature search capabilities required.
Self-directed; able to work effectively and efficiently with multiple interruptions and changing work priorities. Strong organizational and time management skills required. Able to make reliable independent decisions using analytical and problem solving skills. Demonstrates initiative and creativity in assigned work. Highly detailed and team oriented.
Demonstrates knowledge of confidentiality as it pertains to HIPAA and the handling of information sensitive to Munson Healthcare.
Provides administrative, technical, educational, and coordinating support to ensure effective, timely, hospital-wide quality assessment and performance improvement activities.
Reports to the Manager of Clinical Quality and the Manager of the Trauma Program.
Collaborates with the Manager of Clinical Quality and/or the Director of Organizational Quality and Patient Safety to prepare required (regularly scheduled and ad hoc) reports to the Quality and Patient Safety Committees, Medical Staff committees, and Hospital Departments as appropriate.
May report directly to the VP of Quality and Safety, Medical Staff Leadership, and peer review/performance improvement committee leaders.