Senior Quality Analytics Coordinator - QIP - Fulltime - Days - Washington Hospital Healthcare System

Division: Quality and Resource Management  

Job Title:  Senior (Sr.) Quality Analytics Coordinator   

Job Code: 12H   

Position Summary

The Senior Quality Analytics Coordinator is responsible for timely and accurate data and reporting for high impact, organization-wide quality incentive programs. This role serves as the technical expert on nationally recognized quality measures (HEDIS, eCQM, CMS Core Set, NCQA, etc.) and closely collaborates with Information Systems (IS) to ensure that data and reporting meet technical specifications and program requirements. Collaborates with IS and operational leadership to ensure front line clinical workflows collect information necessary for reporting. Collaborates with outside organizations to acquire and integrate outside data as needed for quality reporting. Serves as a quality measure steward advising on improvement strategies to maximize performance. Leads statistical analyses and outcome measurement activities. Provides guidance to others on measurement and analysis activities.  Participates in regulatory audits for quality measurement validation. Maintains expertise in quality measurement trends at the national and state level.    

In addition to performing the essential functions listed below, may also be assigned other duties as required.  

Statement of Accountability  

Reports to: QIP Program Manager   

Qualifications  

• Education
• Licensure
• Work Experience
• Skills/computer/ specific technical
• Other qualifications, miscellaneous

Specify if qualifications are Required or Preferred  

1.     Bachelor Degree in health or data science related field required.    

2.     Master’s Degree in Health Care Administration, Public Health, Public Administration, Data Science, or a related field preferred.   

3.     Experience in the interpretation and technical application of standardized health care quality measurement methodologies (HEDIS, eCQM, CMS Core Set, NCQA, etc.) required. Experience leading these efforts, preferred.   

4.     Five years of experience in health care quality measurement or quantitative analysis required.   

5.     Experience with Epic application build, Slicer-Dicer, and Reporting Workbench preferred.   

6.     Experience managing multiple data and/or quality projects simultaneously required.    

7.     Certified Professional in HealthCare Quality (CPHQ) preferred.   

8.     Experience in data management and advanced data analysis required.  

9.     Ability to express technical information to audiences of varying educational and clinical backgrounds in an understandable manner.     

Achieving Results

Key Components: assess, plan, evaluate, demonstrate initiative, quality of work, productivity  

1.      Responsible for timely and accurate quality reporting for high impact, value-based, quality incentive programs in inpatient and outpatient healthcare delivery settings.     

2.      Leads the development, and ongoing maintenance, of quality reporting that adheres to standardized quality measurement specifications (HEDIS, CMS, eCQM, CMS Core Set, NCQA, etc.).    

3.      Serves as a quality measure steward for the QIP Program, and quality improvement leaders and staff, providing technical expertise in the interpretation and implementation of nationally recognized quality measurement methodologies (HEDIS, CMS, eCQM, CMS Core Set, NCQA, etc.).  

4.      Evaluates quality measure technical specifications and provides guidance to IS on accurate report development.    

5.      Lead and conducts extensive data validation through various mechanisms to ensure data integrity.    

6.      Effectively translates complex technical measure specifications to various audiences including clinical and administrative staff.    

7.      Collaborates with outside organizations (Managed Care Plans, County Health Departments, State Agencies, etc.) to obtain and share data as required for quality measurement and reporting.     

8.      Works with IS to effectively integrate outside data sources into quality reporting as needed.        

9.      Advises on use of quality measures and performance improvement strategies to maximize performance.       

10.  Develops and/or collaborates with IS to develop meaningful data visualizations to monitor metric performance, including quality dashboards.   

11.  Develops standardized processes, tools, and templates for internal reporting and analytics to support quality and process improvement.   

12.  Provides analytical and technical support to teams as needed for advanced analysis activities.    

13.  Leads and conducts statistical and data analysis and outcome measurement activities.    

Demonstrates Skill

Key Components: competency, job knowledge, organizational skills, analytical skill, management of information, employee & patient safety  

1. Demonstrates a strong command of standardized methodologies used in quality measurement reporting including measure intent, technical specifications, value sets, and exclusion/inclusion rules.     
2. Stays abreast of trends in quality reporting. Assess impact of trends to WHHS and communicates with leaders and stakeholders. 
3. Demonstrates knowledge and competency with health care coding nomenclature commonly utilized in quality reporting and associated measure value sets. 

1. Demonstrates knowledge of mechanisms to meet quality reporting standards in a health care setting, for example, utilization of local mapping to standard codes sets.   
2. Demonstrates effective use of data visualization, analytic, and database software. 
3. Leads and/or participates in testing and validation processes for data and clinical workflows.
4. Supports data collection in an ongoing and systematic manner.
5. Collaborates with IS, Finance, and others to ensure data is validated, accurate, and provided timely to stakeholders.
6. Maintains a working knowledge of process improvement principles and measurement tools.
7. Ability to manage multiple projects with extensive data output simultaneously.
8. Ideally, has experience with population health management analytics and software. 

Planning & Coordinating  

Key Components: delegates, decision making, problem solving, management of resources  

1. Effectively manages multiple projects simultaneously and appropriately prioritizes them. 
2. Takes initiative to solve problems by researching solutions and leveraging resources and expertise within, and outside of, the organization. 
3. In collaboration with management, supports planning for the future of value based, quality incentive programs.
4. Informs manager of activities, needs, and problems within areas of responsibility. 

Professionalism

Key Components: dependability, interpersonal skills, teamwork, patient first ethic, customer service, communication skills, punctuality/attendance, receptiveness to criticism, judgment, confidentiality  

1. Builds effective working relationships and strong communication at all levels throughout WHHS/WTMF and with external organizations.

1. Acts in a manner that promotes dialogue, open communication and positive working relationships.
2. Demonstrates self-direction.
3. Seeks feedback and continually works on areas for improvement as provided by manager and peers.
4. Educates and communicates with others in regards to quality measurement and data analytics.   

Improving the Organization  

Key Components: performance improvement, quality initiatives  

1. Promotes alignment, standardization, and integrity in quality measurement across the organization.
2. Participates in initiatives to streamline and standardize quality measurement and reporting. 
3. Aims to streamline data collection, processing, and analysis through automation where possible.
4. Utilizes data to identify and communicate opportunities to improve quality of care including health disparities, and other metrics that align with strategic priorities.
5. Actively strives to improve quality and efficiency through the identification of improvement opportunities and collaboration with quality improvement leaders and staff.
6. Participates in Hospital committees as needed.
7. Participants in Lean/ Kaizen activities as requested.
8. Achieves greater productivity and efficiency with workload.

Self-Development

Key Components: maintain license/certification, education and training  

1. Maintains expertise and stays abreast of trends in health care quality measurement.
2. Identifies opportunities and engages in education and/or training to enhance professional development. 
3. Seeks the opportunity to learn from others in the organization

Regulatory Compliance  

Key Components: JCAHO, Title 22, OIG, HIPAA, State/Federal laws, hospital policies  

1. Follows all Hospital and department policies and procedures.
2. Understands and adheres to policies with regard to HIPAA, JCAHO, and other mandates by State and regulatory agencies.

Prepared by:  

Sabrina B. Valade  

Date:   

07/31/23  

Approved by:  

Title:   

Date:  

Approved by:  

Title:   

Date:  

Personnel Office Review:  

Date:  

Revised Date:  

Lifting Objects/Patients  

Back Injuries  

Hernias  

Understand A&P of back, causes of back pain, preventive approaches, use of aids when lifting.  

Preventive measures when lifting and use aids when lifting.  

Slip/Trip/Falls   

Contusions, Sprains, Strains  

Avoid undue speed.  Use handrails.  Clean up spills immediately.  

Possible Falls  

Contusions, Fractures  

Employees often must use ladders and do some climbing as part of their job.  Employees should never use ladders in need of repair.  Employees should follow safety procedures as outlined in department.  

Fires & Natural Disasters  

Burns & All Types of Injuries  

Recognize possible causes of fires.  Smoking materials, faulty equipment.  Employees should educate patients.  Compressed gasses are flammable & under pressure so must be handled with care.  Workers need to be familiar with disaster plans and know exit routes.  

Electrical Hazards  

Shocks & Burns  

Be aware of unsafe equipment and appliances.  Complete electrical safety training and seek assistance if any unsafe areas are noted.  

Assaults  

Minor Injury to Death  

Employees need to be cognizant to potential dangers to ensure safety.  Awareness of existing security measures and defensive behavior can protect employee from assaults.  

Needles & Sharps  

Cuts, Punctures, Lacerations  

Sharps should be discarded in designated containers.  Employees should exam & handle soiled linens & similar items as if they contained hazardous items.  

Obstacles & Broken Objects  

Abrasions, Contusions, and Lacerations  

Arrange furniture to allow free movement about the room.  Keep doors & drawers closed when not in use.  Clean/discard broken objects properly (i.e. broken glass should be swept up - not picked up with fingers).  

Possible Exposures to Infections Hepatitis/Tuberculosis/Cytomegalovirus/Varicella/AIDS/Herpes/Staph Infections, Lice/Scabies/Rubeola  

Infection  

Use Infection Control procedures as defined in Infection Control manual.  These include handwashing, protective clothing, knowing the risks.  Label linens and wastes properly.  

Latex  

Dermatitis to death  

Alert supervisor if you feel that you are allergic to latex materials. Use non-latex gloves for sterile procedures.  

Soaps, Detergents, Cleaning Solutions  

Dermatitis  

Follow Departmental procedures.  Protective clothing is available if Dept. is unable to substitute agents that do not cause dermatitis.  

Possible exposure to radiation  

Sterility, Cancer, Shortened Life Expectancy  

When appropriate, employees should wear film badges (they are monitored routinely) and use lead aprons, gloves, or shields.   

Possible Exposure to Chemotherapeutic Agents  

Refer to HazMat Binder  

Be aware of procedure for chemo spills.  

Possible exposure to acids & other chemicals used within the hospital  

Refer to MSDS's  

Employees should follow procedures as explained in their department Hazardous Material training and refer to MSDS's before using/handling any chemical.  Follow procedures and do not use any chemical without proper labeling.  

Possible Chemical Exposure  

Refer to MSDS's  

Employees work with a variety of chemicals within the lab setting.  Employees receive training upon hire and also are expected to review the Chemical Safety Plan yearly.  Employees are expected to follow safe working procedures as instructed.  

Exposure to Chemical Agents  

Burns  

Irritations  

Burns & Irritations  

Ammonia solution is frequently used as cleaning agent and the gas is used as a refrigerant.  Gloves should be worn and other precautions as described in training and MSDS.  

Chlorine solutions are often used as disinfectants.  Gloves should be worn and other precautions as described in training and MSDS.  

Drain cleaners are often used and splashing may occur.  Protective clothing should be used and other precautions as described in training and MSDS.  

Exposure Microwave Radiation  

Radiation Effects  

Doors may not close completely due to: hinges & catches may loosen; spilled food; if interlock system fails.  Regular maintenance is done but employees should report any problems & clean all spills.  

Possible Heat Stress  

Weakness, Nausea, Dizziness  

Employees need to be aware of symptoms and the need for water consumption.  

Possible injuries due to Improper Storage  

All types of injuries  

Employees should follow safety procedures of fuel & Cylinders of Oxidizing Gas as outlined in their department.  

Possible exposure to Waste Anesthetic Gases  

Health Effects per MSDS's  

Employees should be cognizant of hazards of anestetic gases and follow procedures as outlined and trained in their department.  

Ergonomic Problems  

Wide Variety of Musculoskeletal nervous disorders  

Body mechanics, positioning of equipment/furniture and repetitive actions can cause employees to experience a variety of physical problems.  Employees should follow safe body mechanics as described in hospital education.  Employees are encouraged to seek assistance from their supervisor if they feel a task is causing them to experience physical problems.  Work site evaluation may be indicated and this should be discussed with manager.                

Exposure to Video Display Terminals  

Eye strain & stress in addition to ergonomic complaints  

It is unknown if significant visual dysfunction results from long-term use of VDT's.  Problems may be controlled with control of lighting and glare, the color contrast, and workers should have adequately corrected vision.  Employees should seek assistance from their supervisor if they feel VDT is causing problems for them.  

Potential Hazards from Office Work  

Variety Musculoskeletal  

Employees need to be cognizant of potential dangers to ensure safety.  Each Dept. provides office safety classes to alert employees to potential dangers.