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Clinical Quality Improvement Specialist
Job Summary This position serves in a dual role involvingdirect in person
coordination with hospital facilities to enhance bothNational
Healthcare Safety Network (NHSN) automated hospitalreporting
along with pediatric readiness capabilities withinhospital networks
and facilities located in Indiana. This position promotesbest practices
and quality improvement processes in both hospitalreporting
importance for the automation transition and pediatricpreparedness
programs/initiatives. The position serves in coordinatingthe
development of statewide guidelines aiding hospitalsinto an
automated platform for hospital reporting educationalmodules and
quality improvement resources/tools utilizing federal andnational
recommendations/guidance evidencebased guidelines andbest
practices specific to the delivery of hospital facilitykey elements
reporting along with pediatric emergency care. Theposition also
serves as a resource and technical advisor toprehospital agencies
hospitals other healthcare practitioners as well asnonhealth care
entities within our state to ensure hospital facilityneeds are
adequately addressed.
Education and/or Work Experience
Registered Nurse (RN) Bachelor of Science in Nursing(BSN) or other
similar certification combined with Hospital experiencepreferred
Bachelor s degree supplemented with 35 years ofprevious hospital
and quality improvement jobrelated experience. Idealcandidate also
has either CPHQ or Lean Six Sigma
Duties and Responsibilities
Assist with development and launching of astate/jurisdiction
capacity system that includes neartime bed capacitycounts
for the state s/jurisdiction s acute care hospitalsincluding
critical access hospitals.
Must be able to manage user account and securityparameters
for access to the webbased dashboard to coordinatedaily
surge and crisis needs.
Help coordinate emergency department data organizedper
NHSN definitions to Hospital Capacity Data Store at leasttwice
per day on an ongoing basis. Data would include emergency
department (ED) census ED Admitted census (boarding) and
ED pressure indicator by count of all patients in the EDthat
have a physician assigned.
Create possible items listed below to support the
states/jurisdiction s ongoing participation in the NHSN
Connectivity Initiative such as:
Develop communications and training materials for
onboarding identified stakeholders and hospital users.
Provide training and onboarding services toparticipating
hospitals and stakeholders.
Work with the state s/jurisdictions hospitals tocollect
necessary information for dashboard development and
implementation.
Provide a common framework of data elements to includeon
the dashboard and in the data feed.
Facilitate the gathering and engagement of hospitals technical
staff to work on automated and secured data feeds per
specifications supported by the webbased application.
Assist the state/jurisdiction to advise on sharedgovernance
model(s) for discussions and decisionmaking to supportthis
work.
Testing and validation of data feeds; and draftprogress
milestone for inclusion in progress report/lessonslearned.
Manages the participation and permissionprocess/clearances
(to send data to NHSN) of participating hospitals. Also
provides permission to allow for use ofstate s/jurisdiction s
data in conjunction with other participating entities for
research and emergency planning by the state and federal
health partners.
Obtain signed commitment from acute care hospitals inthe
state/jurisdiction to participate in the project throughan
established participation agreement.
Provide ongoing instructions and serve as key resourceto
assist with the scaling of the CDC NHSN ConnectivityInitiative
to other states/jurisdictions; and help to ensure thatall terms
of the CDC funding agreement are met.
Facilitates efforts to improve clinical and serviceoutcomes
throughout the state as related to pediatric emergencycare
utilizing federal/national guidance (including but notlimited to
the American Academy of Pediatrics Assistant Secretaryfor
Preparedness & Response Centers for Disease Control
Emergency Medical Services for Children FederalEmergency
Management Agency Institute of Medicine JointCommission).
Works with Indiana Emergency Departments to assessareas of
need conduct gap analyses communicate pediatricstandards
and disseminate resources as appropriate.
Develops and facilitates bimonthly State PediatricEmergency
Care Workgroup meetings and actively assumes project
leadership responsibilities through planningcoordination of
workgroup activities and development of toolseducational
modules and resources for workgroup review.
Participates as a team member on hospital site visitsconducted
throughout the state to assess compliance with pediatric
emergency care requirements and regulations using defined
checklists; provides verbal and written assessment ofhospital
strengths/weaknesses; outlines recommendations and other
key subject matter expertise as appropriate; sharesapplicable
resources and technical guidance with hospitals asneeded.
Develops documents annually to promote qualityimprovement
practices as related to pediatric emergency caredocuments
and development of a quality improvement plan.
Engages in and demonstrates selfdevelopment inclinical and
professional knowledge base in the areas of pediatric
emergency management quality improvement processes
communication and awareness of trends in the healthcare
environment.
Utilizes data to identify trends draw appropriateconclusions
and make recommendations; develops data reports for
decisionmakers to support conclusions and
recommendations; reports should communicate anylimitations
of the analyses.
Facilitates efforts to improve clinical and serviceoutcomes
throughout the state as related to pediatric emergencycare
utilizing federal/national guidance (including but notlimited to
the American Academy of Pediatrics Assistant Secretaryfor
Preparedness & Response Centers for Disease Control
Emergency Medical Services for Children FederalEmergency
Management Agency Institute of Medicine JointCommission).
Works with Indiana Emergency Departments to assessareas of
need conduct gap analyses communicate pediatricstandards
and disseminate resources as appropriate.
Develops and facilitates bimonthly State PediatricEmergency
Care Workgroup meetings and actively assumes project
leadership responsibilities through planningcoordination of
workgroup activities and development of toolseducational
modules and resources for workgroup review.
Participates as a team member on hospital site visitsconducted
throughout the state to assess compliance with pediatric
emergency care requirements and regulations using defined
checklists; provides verbal and written assessment ofhospital
strengths/weaknesses; outlines recommendations and other
key subject matter expertise as appropriate; sharesapplicable
resources and technical guidance with hospitals asneeded.
Develops documents annually to promote qualityimprovement
practices as related to pediatric emergency caredocuments
and development of a quality improvement plan.
Engages in and demonstrates selfdevelopment inclinical and
professional knowledge base in the areas of pediatric
emergency management quality improvement processes
communication and awareness of trends in the healthcare
environment.
Utilizes data to identify trends draw appropriateconclusions
and make recommendations; develops data reports for
decisionmakers to support conclusions andrecommendations;
reports should communicate any limitations of theanalyses.
Other duties as required.
Computer Skills
Microsoft Teams Power BI Microsoft Outlook MicrosoftWord
Microsoft PowerPoint Microsoft Excel Basic KeyboardingSkills Web1basedmeeting and learning management systems REDCap
Computation Ability
Ability to solvepractical problems and deal with a variety of concrete
variables in situations where only limitedstandardization exists. Ability
to interpret a variety of instructions furnished inwritten oral diagram
or schedule form.
Qualifications
Ability to maintain accuracy and consistency
Ability to finish tasks in a timely manner
Ability to function independently manage own time/worktasks
Ability to maintain confidentiality
Ability to interact with internal and externalconstituents
Ability to work as an effective team member
Ability to organize workflow
Ability to plan coordinate and develop multipleprojects
Ability to analyze and interpret data
Ability to compile complex reports and developpresentations
Ability to compose letters and memorandums
Ability to negotiate persuade and establish direction
Skilled job requiring high level of adaptability andinterpersonal
skills
Must be able to work in a fastpaced dynamicenvironment and
adapt to changing priorities
Travel
Instate travel will be required as needed and out ofstate
overnight may be necessary.
Expect NA% of work week traveling around state ofIndiana
Full Time