Registered Nurse-Quality Outcome Analyst

Eisenhower Medical Center, Rancho Mirage, CA
Nov 10, 2017
Dec 04, 2017
Contract Type
Full Time

Job Objective: A brief overview of the position.

    The Quality Outcomes Analyst will assist in measuring and analyzing clinical data to improve quality of patient care and cost-efficiency for the organization.

Reports to

    Director, Quality



Ages of Patients


Blood Borne Pathogens

    Minimal/ No Potential



      Required: BSN or MSN or enrollment in an RN-BSN or RN-MSN program within 1 year of hire and completion within 5 years of hire if hired after July 1, 2012


      Required: California RN license

      Preferred: Healthcare Quality Certification (CPHQ), Certified Professional in Patient Safety (CPPS), or other relevant certification


      Required: Two years’ experience in performance / quality improvement activities and/or two years’ experience as a registered nurse.

Essential Responsibilities

    Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.

    Participates in regulatory body surveys (e.g. Joint Commission, California Department of Public Health) and assist in monitoring of action items as requested.

    Coordinates the Joint Commission (TJC) readiness education activities (e.g. audio conferences).

    Assists with TJC Periodic Performance Review (PPR) and disease specific certification process by providing structure and process to organization stakeholders.

    Assures accreditation survey reference-documentation binders are updated routinely.

    Coordinates and schedules facility-wide TJC tracers, including distribution of results and requests for follow-up from various department.

    Facilitates meetings/projects that support TJC, CDPH, CMS and other regulatory readiness (e.g. Sentinel Event Alert Gap Analysis/ Action Plan Teams, Proactive Team Assessments and Mock Survey Response Teams).

    Researches current findings of best practice and provide this information to appropriate clinical performance improvement teams.

    Acts as facilitator and minute keeper for PI teams as required.

    Analyzes, disseminates, and presents hospital outcomes data using statistical tools (i.e. process control charts, descriptive statistics, etc.) in an appropriate manner, as requested.

    Prepares reports illustrating quality measures, data and recommendations.

    Implements tracking systems to measure the effectiveness of interventions.

    Communicates with team members and participates in appropriate committees to report process-outcome information.

    Provides education to customers regarding process-outcomes data, specific data elements and other issues as identified.

    Supports Root Cause Analysis process as requested.

    Documents conclusions, recommendations and actions of Root Cause Analysis Meetings and distribute to appropriate individuals for follow up as requested.

    Assists with projects supporting the Quality Department (e.g. identification of clinical financial-process measures to improve clinical outcomes and cost-efficiency, cost analysis based on research and financial data).

    Assists with Quality Council agenda, minutes, follow-up, and related reports for medical committees and Board of Director, as directed.

    Acts as a quality improvement leader and is a resource to the hospital, and the medical staff regarding TJC, CMS, and Title 22 standards.

    May support Medical Staff Quality Improvement/Peer Review Committees as appropriate

    May be responsible for core measure abstraction

    May assume coordinator responsibilities for the Sepsis core measure

    May act as an assistant to the Infection Preventionists
  • Performs other duties as assigned.