Quality Improvement Specialist

Title Quality Improvement Specialist

Cost Center: 10000-50052-001694

Reports To : The Director of Quality and Safety 

Position Objective:

 The Quality Specialist collaborates with Luminis Health operational staff, nurses and providers to design and deploy processes to meet and exceed top deciles performance and regulatory requirements based upon the health systems strategic and annual operating plans.  Deploys a data-driven approach to optimize evidence based, safe, high quality care, treatment and service for patients, families, staff and physicians.

Essential Job Duties:

1. Collaborates with Luminis Health clinical Service Line dyad leads  to ensure mutual understanding of data source(s) and data dictionary and works to identify quality/process improvement projects to drive performance
2. Interfaces with Information Systems to abstract clinical data, generate reports, and identify opportunities for recognition or performance improvement. 
3. Ensures reliability and validity of evidence-based care through direct observation and monitoring data.
4. Collaborates with Division and LH Data Specialists to ensure data visualization and narrative effectively communicates insights from a dataset(s).
5. Analyzes documentation and data for Maryland Hospital-Acquired Conditions, Potentially Preventable Conditions and and other Maryland HSCRC specifications and inspires improvement activities for the health system
6. Cross trains with other Specialists to be able to assure Department integration and synergy. Assists with execution of the annual Leapfrog Survey and convenes teams to improve opportunities identified.
7. Performs concurrent chart reviews and retrospective analysis of patient records based upon Regulatory Requirements and identified opportunities for improvement in care, treatment and service.
8. Performs medical reviews based on identified criteria. Provides consultation to staff, department managers and medical staff regarding data findings and to promote accurate documentation.
9. Utilizes Lean Six Sigma, TeamSTEPPS  and Just Culture principles/tools when collaborating with peers, colleagues and medical staff to improve quality and safety of care. 
10. Supports and collaborates with the Director of Quality and Safety and other leadership as directed for presentation of outcome data at department meetings for the purpose of quality improvement.Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Educational/Experience Requirements:

• At least three years of experience in Quality Improvement.  Clinical experience and RN/BSN degree preferred.
• Lean Six Sigma Green Belt (LSSGB) Certification, and experience with Just Culture and TeamSTEPPS preferred. Must obtain LSSGB within first 2 years of employment. CPHQ preferred.