Responsible for assuring compliance with mandated clinical interventions inclusive of core measures within the medical center. Interfaces directly with MSMC Departments, Administrators, Nursing, Medical and Quality Leadership, and Clinical Staff, overseeing administrative and daily operations of the core measures and clinical intervention compliance program.
Duties and Responsibilities:
1. Coordinates core measures and clinical intervention compliance activities in conjunction with Nursing, Medical and Quality Leadership
2. Assists in design and development of action plans to support compliance with measures indicators and provides support and educational resources to departments and services relative to core measures quality assessment and improvement processes.
3. Assists in establishing and implementing short and long term goals, objectives, policies and operating procedures for core measures programs.
4. Provides coordination and leadership in the execution of day to day program activities, as appropriate to program objectives and areas of expertise.
5. Oversees the collection, compilation, and analysis of clinical program activity data.
6. Provides technical assistance, resource services, consultation and education to clinical departments relative to core measures activities.
7. Participates in and conducts process improvement analysis where applicable.
8. Promotes an interdisciplinary approach in patient care delivery.
9. Serves as a resource for patients and their families. Acts as a patient advocate utilizing the Patient Bill of Rights.
10. Prepares reports and analysis associated with the institutions core measures programs i.e. senior management reports, departmental and clinical service program evaluation, quarterly reports, etc.
11. Provides timely status reports of results of quality monitoring relative to areas that are assigned including identification of patterns and trends that require actions.
12. Collaborates with other members of the health care team in the development, implementation, and ongoing review of policies, procedures, and standards of care for designated patient populations.
13. Demonstrates knowledge of hospital, departmental and care center standards, policies, procedures and guidelines as well as regulatory agency standards. Assures readiness for Joint Commission and other agency surveys and presents related programs during Joint Commission and other agency visits
14. Participates in the development and implementation of continuous quality improvement programs.
15. Participates in quality management activities including identifying and communicating issues of performance improvement and risk in a timely manner.
16. Assists in the performance appraisal process of designated Nursing staff.