Description:

DMC Sinai-Grace Hospital is DMC’s largest hospital, offering a comprehensive heart center, cancer care, gerontology, emergency medicine, obstetrics/gynecology and cosmetic services. Sinai-Grace’s joint replacement program features a revolutionary minimally invasive knee and hip replacement surgery that attracts patients from all over the country. Sinai-Grace operates more than 21 outpatient care sites and ambulatory surgery centers throughout Wayne and Oakland Counties and is one of 10 hospitals in the nation to be awarded a Robert Wood Johnson Foundation grant to help set the standards of cardiac care for hospitals and physicians throughout the nation.

Summary Description

Under general supervision, directs and coordinates all aspects of assigned registry including data collection. data submission, quality report issues, outcome report review and analysis Acts as administrative contact to the registry or projects assigned responding to all requests from the registry for information to include: clinical interpretation of data element definitions; data submission process; data quality and cleaning; data submission to meet regulatory or stakeholder requirements, review of comparative institutional reports and use of outcome reports for quality measurement and improvement.

Interviews patients and/or accesses the patient’s medical records and abstracts required clinical data. Responsible for the timely and accurate collection of data and entry/upload into the web-based program, as applicable.

Participates in project training sessions and meetings, and maintains regular contact with the registry staff, assigned project’s physician champions, nurses, and other clinicians and administrators.

Serves as a source of clinical expertise in measurement of outcomes of care. Promotes consistent application, effective processes and accountability for the clinical improvement program.

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 and organizational goals. Keeps appropriate parties apprised of overall progress and monitors project results for significant deviations; proposes actions to ensure that timelines and deliverables are met; reviews project deliverables to ensure they meet standards and objectives.

Contributes to the development of policies and procedures related to the clinical improvement program. Based on clinical knowledge of and experience in the delivery of patient care, consistent with Registered Nurse licensure, compiles, analyzes, interprets, and evaluates clinical and quality data collected as part of an integrated system-wide program of clinical improvement.

Identifies opportunities for clinical improvement and involves the appropriate personnel. Facilitates and/or leads clinical improvement team efforts.

Conducts or facilitates education of medical and hospital staff regarding continuous improvement methodology, tools and measurement. Assists clinicians in understanding measurement for improvement of practice.

Participates in the ongoing development of clinical improvement and measurement of its effectiveness. May provide leadership to the Data Analysts in the Quality & Safety Department.

Qualifications:

Minimum Qualifications

1. Graduation from an accredited school of nursing. Bachelor’s degree in Nursing (BSN) preferred.
2. Licensed to practice as a Registered Nurse (RN) in the state of Michigan.
3. Three years of progressively more responsible clinical and/or quality improvement/process improvement experience, including at least one to two years of experience in health care quality management and the application of continuous improvement methodologies, tools, standards, and guidelines.

Skills Required

1. Analytical ability and comprehensive knowledge base to identify opportunities for improvement and problem resolution, to evaluate clinical improvement procedures/techniques, analyze and interpret a variety of data, and promote the translation of research into operational improvement.
2. Interpersonal, verbal and written communication skills necessary to facilitate communication and interaction with all levels of hospital personnel, medical staff and external agencies and organizations.
3. Teaching abilities to conduct educational programs for staff.
4. Organizational skills to effectively coordinate all aspects of the clinical improvement program.
5. Ability to cope with stressful situations, manage multiple and sometimes conflicting priorities simultaneously.
6. Leadership skills to direct and facilitate others toward objectives that contribute to the success of the department.
7. Ability to facilitate groups related to clinical and performance improvement.
8. Technical knowledge of the principles of clinical process improvement, including reduction in practice variation, the role of feedback to clinicians, the interdisciplinary nature of improvement and the evolution of health information to support improvement.

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