Job Summary:

The Performance Improvement Coordinator is responsible for data abstraction for required reporting entities. Participates in ensuring accurate and timely review of all Core Measures. Provides education to staff to ensure compliance. Participates in Performance Improvement Patient Safety Committee (PIPS) and in survey readiness activities. Is responsible for coordinating with the individual departments to determine quality metrics/data to be tracked and reported

Responsibilities:

• Performs medical record reviews associated with Quality Improvement
• Analyzes data collected for Quality Improvement projects, core measures
• Data abstraction and reporting for all applicable National and State reporting agencies
• Works with hospital department managers/directors to coordinate data management
• Develops appropriate reports for use by the Director of Quality/Risk
• Demonstrates knowledge or requirements by Joint Commission and CMS
• Keeps updated with current regulations affecting the Core Measures
• Responsible for eCQM monitoring, data collection and reporting, with assistance from the IT/IS department
• Actively participates in Department of Nursing committees and Hospital committees
• Performs other duties as assigned or required
• Participates actively and positively affects the outcome of customer service activities
• Participates actively and positively affects the outcome of customer service activities
• Demonstrates and maintains thorough knowledge of Federal, State, Local Laws and CMS/JCAH accreditation standards
• Understands and actively participates in the hospital-wide Quality Improvement Process using the Plan/Do/Check/Act (PDCA) process
• Is able to define performance improvement and verbalize at least one departmental or hospital-wide improvement initiative that has occurred in the last 12 months
• Follows standard precautions and transmission-based precautions as demonstrated by consistent use of appropriate personal protective equipment
• Uses proper body technique at all times. Seeks assistance when necessary to move heavy objects or to transport/transfer a patient

Education and Experience:

• Must have a current and valid license as a Registered Nurse issued by the state of Ohio
• Minimum of 3 years of healthcare experience
• BLS upon hire and maintain current
• Excellent computer knowledge including Excel, Windows, spreadsheets, graphing, charts, PowerPoint/slide presentations
• Ability to manage and analyze data

Required Skills/Abilities:

• Excellent analytical and writing skills
• Strong computer skills to include Microsoft Word, Excel, PowerPoint, and database products
• Must be highly motivated and willing to assume additional jobs and duties as needed
• Must be able to handle stress of working efficiently with frequent interruptions and distractions
• Hours must be flexible to accommodate for needs during Accreditation surveys or other unscheduled events
• Must be able to prioritize tasks and adhere to strict deadlines

Physical Requirements:

• Sitting 3-6 hours a day
• Wrist deviation (side to side and up and down) 3-6 hours a day
• Occasionally lift up to 50 pounds
• Occasionally be exposed to hazardous chemicals or infections