This position is responsible for sustaining systematic organization-wide Performance Improvement, the medical staff peer review activities on quality of care and comparative data and focus studies in accordance with the PI plan, Medical Staff Bylaws, Rules and Regulations and the Peer Review policy and procedure. The PI Analyst II must have data visualization and presentation skills, both written and verbal. This position must have the ability to teach various audiences about data, interpretation and limitations and can prioritize multiple requests for data analysis.

The PI Analyst II is also responsible for promoting and supporting Performance Improvement and Quality Assessment activities throughout the organization by offering data and analysis substance for PI teams. The position is actively involved in the design, assessment, and measurement of important processes and outcomes that may affect the delivery of quality patient care, operational processes and strategic initiatives. This position is also responsible for assisting the Director of Performance Improvement in the implementation, support, direction and further enhancement of clinical data and tracking mechanisms, including assisting the CSC in support of all Clinical Research Processes at the facility as needed.

Work Schedule

8 a.m. to 5 p.m. Monday through Friday and occasional weekends depending on the needs of the hospital

Primary Duties

Quality Sciences:

1. Sustains quality activities in accordance with the Performance Improvement Plan.
2. Sustains the systematic organization-wide peer review program. (See Medical Staff Activities)
3. Maintains the statistical reporting for ACC, STS, CORE Measures, GWTG, and other programs as required and assigned.
4. Facilitates and supports the Performance Improvement Committee meetings and activities as needed.
5. Assists PI Director with project status and development.
6. Provides to the PI Director for the governing board, administrative and medical staff bodies required quality reports containing findings from data analysis and review activities as needed.
7. Demonstrates a working knowledge of the medical staff and governing body bylaws, rules and regulations and affiliated policies and procedures.
8. Analyzes, finds and corrects data to support regulatory requirements per regulatory updates and other memorandums.
9. Serves as the content expert for all assigned areas, data and tracking mechanisms.
10. Makes process recommendations based on results of data analysis from assigned areas.
11. Participates in chartered and needed quality team activities as assigned.
12. Supports and promotes the scientific methodologies of quality: i.e. PDCA, Lean, and DMAIC.
13. Ensures that collection, assessment and analysis of data occurs for teams, selected processes studied, clinical practices, operational and clinical outcomes, and other pertinent functions.
14. Reports data using statistical and scientific methods.
15. Assists the PI Director on team process: close the loop on quality studies in a timely manner and develop and implement a control plan to maintain the gain and prevent process or system entropy.
16. Responsible for entry of data into the Midas system or other spreadsheet function for analysis and reporting of variation; and, supports the system administrator for Midas.

Medical Staff Activities:

1. Provides education to medical staff members on data from ACC, STS, Core Measures and other programs as required and assigned.
2. Provides quality profile information for the medical staff reappointment process from the assigned resources.
3. Assesses, evaluates and monitors specific quality of care concerns and perform special studies as necessary, and report findings to the appropriate committees as assigned
4. Actively participates in and support medical staff peer review activities on quality of care, comparative data and focus studies in accordance with the PI plan and Peer Review policy and procedure.

    

   Relationship Building:

1. Accepts positive and negative constructive feedback.
2. Demonstrates a supportive/positive attitude toward the hospital and fellow employees.
3. Demonstrates a teaching and consultative approach to the quality sciences.
4. Provides and identifies resources and shares as appropriate.
5. Participates in education and development programs.
6. Maintains and promotes a team spirit through active cooperation and collaboration.
7. Fosters team development through the use of team building and development tools.

Results Oriented:

1. Ability to demonstrate measurable results and achievements.
2. Effective in cost control and resource utilization.
3. Maintains and develops personal professional competency through the use of a learning plan.
4. Effective at taking action on analyzed data, improvement opportunities and then bringing the actions to closure in a timely manner.
5. Data entry, analysis and actions are accurate, timely and pertinent.

Customer Service Indicators:

1. Maintains positive relationships with internal and external customers.
2. Proactive in meeting the customers needs by using appropriate quality science tools.
3. Responds promptly to customer needs or requests.

Leadership and Role Modeling:

1. Expresses self in an organized, comprehensive, articulate and concise manner.
2. Participates with performance improvement group and other best practice and task force teams through conference calls and meetings as needed.
3. Demonstrates extensive use of the Midas program for quality and credentialing services.
4. Supports strategic planning, balanced scorecard and business planning efforts as needed as assigned;

    

Critical Thinking Application:

1. Demonstrates consistent approach of balancing ownership and accountability to all participants.
2. Is statistically minded using inductive and deductive reasoning when problem solving.
3. Uses resources appropriately to augment personal skills and knowledge to help achieve world-class quality outcomes for the hospital.
4. Effectively uses selected and approved computer system and programs to manage projects, data and reports.

Project Management:

1. Supports quick turnaround of two days for most quality efforts.
2. Provides PI Director with project and data analysis / management updates.
3. Meets deadlines for regulatory compliance and project completion.
4. Manages processes effectively for ACC, STS, Core Measurement, CMS, PRO, and Interqual studies via data abstraction, analysis, action plans and reporting as assigned.

Regulatory Compliance:

1. Assists in compliance with JCAHO, Medicare, and State standards as needed.
2. Assists with mock survey processes as needed.
3. Works in tandem with the PI Director to achieve full compliance with regulations.

• Education: Bachelor of Science degree in Nursing required. Specialized training in statistical process control (SPC), Performance Improvement, Quality Assessment and Assurance and Regulatory Management required. Training and education in Performance Improvement tools and techniques required.
• Licensure/Certification: Licensed as a Registered Nurse. Green Belt certification preferred.
• Experience: Minimum of five years in clinical nursing required. Cardiac Critical Care nursing strongly preferred. ACC, STS and Core Measure expertise needed for this position. Has demonstrated knowledge of relational databases and medical information systems and statistical methods and applications.
• Interpersonal Skills: Must have the ability to effectively communicate knowledge and information to all hospital staff, team members, physicians, patients and families. Ability to communicate in English, both orally and written. Ability to work individually and in a team setting.
• Technical Skills: Proficient in computers for the following programs: Excel spreadsheets and statistical tools such as ANOVA; Quality America, SAS, JMP, or other required statistical software tools; process management computer tools such as Visio, ClearProcess or similar program; Midas quality management proficiency necessary; able to create reports and communicate progress; able to independently use office equipment, fax, copier, etc. Requires the ability hear and verbalize information. Must have the ability to accurately complete database requirements for Medicare, TJC and other required organizations.
• Essential Physical Requirements: Must be able to stand and walk for prolonged periods of time.
• Essential Cognitive Abilities: Able to interpret rules/regulations/accrediting and licensing standards sufficiently for implementation; to maintain concentration and organize while dealing with multiple issues; and, to analyze data and formulate plan of action. Requires good communication and organizational skills, reasoning ability and good independent judgment. Requires working under stressful conditions and irregular hours and working with frequent interruptions. Must be able to do mathematical calculations including statistical methods related to performance improvement and Six Sigma quality activities.
• Essential Mental Abilities: Individual must have good mental health and the ability to read, write and comprehend instructions.
• Essential Sensory Requirements: Must have corrected hearing and vision within a normal range. Must be able to diplomatically respond to administrative and governing bodies, medical staff members, hospital personnel, patients and visitors. Able to collect sensory input, analyze political dynamics, and intervene as needed.
• Exposure to Hazards: Requires exposure to communicable diseases and potentially contaminated body fluids and hazardous materials. OSHA risk factor: Category I.
• Other: Has working knowledge of the Balanced Scorecard and its linkages to quality studies and measurement. Understands the mission and vision of the hospital. Operates within the concept of patient focused care. Evolves into an effective team member. Must adhere to dress code: good grooming and personal hygiene habits; and strict adherence to attendance policies. Maintains knowledge of and conforms to hospital policies and procedures.

Key Relationships

1. Maintains positive relationships with internal customers. Is effective in interacting with others and problem-solving.

2. Maintains positive relationships with external customers. Is effective in interacting with others and problem-solving.

3. Proactive in meeting customers needs.

4. Responds promptly to customer needs or requests.

5. Keeps management informed of problems, recommends solutions.

6. Participates in education/development of peers and other staff.

7. Inspires and encourages confidence in subordinates.

8. Always receives positive evaluations from subordinates.

9. Communicates achievements of individuals and teams in a visible and positive way.

10. Provides timely, descriptive feedback regarding personal and professional issues.

Initiative

1. Develops specific work plans and due dates.

2. Follows through on planned assignments within assigned timeframes.

3. Effectively prioritizes assignments.

4. Demonstrates a willingness to accept extra assignments.

5. Adjusts to change, work pressures or different situations without undue stress.

6. Demonstrates skill in developing improvements in work methods.

7. Aggressively seeks and implements work method improvements.

8. Effective in cost control and resource utilization.

9. Assists in the overall operation of the hospital through active participation in projects aimed at achieving the hospitals mission; incorporates the values and vision of the hospital in day-to-day activities.

Professionalism

1. Demonstrates professional behavior to set an example for subordinates.

2. Maintains positive spirit/attitude at all times.

3. Adheres to dress code, conduct and attendance policies.

4. Accepts both positive and negative constructive feedback.

5. Attends and/or conducts in-services and departmental meetings.

6. Demonstrates a supportive/positive attitude toward the hospital and fellow employees is a positive team member.

7. Expresses self in an organized, comprehensive, articulate and concise manner.

8. Attend at least 80% of in-services and department meetings.