Quality Improvement Coordinator

SUMMARY:

Under the leadership of the Chief Medical Officer, the QI Coordinator helps to facilitate quality improvement efforts throughout the organization. Monitors and helps develop quality improvement projects to meet LACHC’s evidence-based goals related to preventative and chronic care for all patients.  Collaborates with other staff to execute the Quality Assurance/ Quality Improvement (QAQI) Plan and related projects. Manages data collection, monitoring, and reporting of clinical performance data and other quality-related data.  Provides accurate, timely information to committees and staff involved with Quality Improvement.  Supports LACHC’s mission “to follow Christ by loving and serving our neighbors through comprehensive, quality healthcare” in all job duties and responsibilities and demonstrate Christ-like behavior and attitude.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

 Includes but are not limited to the following: (Other duties may be assigned.)

Quality Improvement (QI):

·         Serve as a champion for Continuous Quality Improvement (CQI) efforts in clinical measures.

·         Monitor and evaluate quality and process improvement projects and activities

·         Participate on the Plan-Do-Study Act (PDSA) Committee, with special emphasis on data-driven results for PDSA evaluation

·         Participate on the clinic Patient Center Medical Home (PCMH) committee, a multidisciplinary team focused on process improvements and tracking of PCMH measures in compliance with the National Committee for Quality Assurance (NCQA) requirements.

• In collaboration with the Director of Nursing, Chief Innovation Officer, and Chief Medical Officer, help ensure ongoing successful maintenance of PCMH certification through annual reporting.

·         Serve as an active member of the Continuous Quality Improvement (CQI) team by reporting on quality measurement and improvement activities, including methods to track implementation of action plans.

·         In addition to working on the teams above, participate as a member, work closely with other members, and help coordinate clinical data strategy efforts of the following teams: Data Governance Committee and Health IT team

·         Implement provider benchmarking reports that depict site and provider performance relating to clinical measures and some operational metrics, including “Hits to Goal”, trends in performance, and performance on QI improvement goals; communicate findings to CMO and to other clinicians when requested.

·         Maintain thorough knowledge of annual Healthcare Effectiveness Data and Information Set (HEDIS) measures and NCQA updates

·         Leverage Electronic Medical Record (EMR), Meaningful Use, HEDIS, and other data reporting systems to demonstrate improvements in clinical performance.

·         Help support and train clinicians, trainees, and other staff during orientation and in other educational settings on quality improvement and performance improvement concepts.

·         Facilitate, develop, and implement special projects as assigned by the CMO

·         Participate in interagency meetings and/or peer groups related to quality and process improvement as needed

Data Management & Health IT:

·         Facilitate data collection and display of clinical quality-related data for internal reports and external reports, such as HEDIS, PCMH, Health Resources and Services Administration (HRSA), Community Clinic Association of Los Angeles County (CCALAC), EMR Meaningful Use Attestation, Uniform Data System (UDS) Reporting, and other reports as needed.

·         Data collection may include manual chart audit and review, generating IT system reports (from EMR, Azara, Interpreta), and data validation

·         Develop and maintain current knowledge of EMR and other IT applications (Azara, Interpreta) to develop internal and external reports.

·         Gather and present clinical performance data for meetings and use of CQI team, PCMH committee, and PDSA committee.

·         Gather, validate, and present selected HEDIS data in compliance with Health Plan goals and incentive matrices

·         Communicate with and train staff on Meaningful Use updates, changes to objectives, and appropriate workflows to improve effective use of our Electronic Medical Record (EMR)

·         Gather and distribute Meaningful Use data periodically to providers, Clinic Managers, CMO, and Chief Operations Officer (COO); work with EMR technicians and appropriate staff to address gaps in data and communicate related initiatives to meet objectives and maximize incentive money

·         Serve as the clinic champion for Azara data warehouse on the Health IT Team, working with the CMO, Health IT team, and other data stewards to monitor data analysis and to establish the most effective, efficient, and excellent use of EMR and Azara.

·         Interact with IT staff as necessary for accurate collection of data.

·         Track progress toward clinical benchmarks, preparing monthly and quarterly reports that are site- specific and provider-specific, tracking trailing year progress on clinical measures required by current federal regulations or grants.

·         Compile data needed for final reports as needed by auditors, grants, etc.

• Maintain current competency and expertise in data analysis as related to quality metrics

·         Serve on the Data Governance Committee

Population Health Management:

·         Run population data queries using EMR registry, Azara, and other data programs as appropriate.

·         Using data from queries, arrange outreach to patients due for follow-up or preventative care by way of phone call, letter, text message or patient portal, in order to reduce gaps in services by promoting continuity of care and follow-up of clients.

·         Participate in root cause analyses in relation to population-based clinical outcomes, collaborating with other QI champions to adjust and improve quality improvement projects. Analyze barriers to effective population- based outreach efforts and make appropriate changes in outreach efforts to maximize effective communication with patient populations.

·         Communicate with members of care teams—providers, medical assistants, front office staff, social services staff, etc- as needed to collaborate in outreach efforts for patients who are difficult to contact

·         Send periodic reports to providers-MD’s, PA’s, NP’s, DDS’, and nurses--regarding their patients who need care or follow-up for clinical measures--i.e., diabetes follow-up, HIV follow-up, cervical cancer screening, breast cancer screening, colon cancer screening, dental follow-up, well-child checks (WCC), immunizations due, prenatal reporting, etc.

·         Generate outreach reports detailing success and issues pertaining to specific outreach efforts.

·         Treat customers, patients, co-workers, and others with dignity, respect and trust. 

• Minister to the needs of the patients in a holistic manner, addressing needs of body, mind and spirit.
• Maintain strict patient confidentiality per HIPAA regulations.

 SUPERVISORY RESPONSIBILITIES:

 Supervise pre-professional Population Health or Quality Improvement Interns when applicable.

QUALIFICATIONS:

 To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Must possess excellent interpersonal skills, and strong written and verbal communication skills.
• Strong analytic skills and ability to use data to drive improvement activities.
• Strong organizational and prioritization skills with ability to collaborate with multiple departments.
• Detail oriented and comfortable working with tight deadlines in a fast-paced environment.
• Ability to work independently under general instructions, self-directed and motivated.
• Must be willing and able to work a varied and flexible schedule to accommodate the needs of LACHC and its patients.
• Knowledgeable and experienced in PDSA or other performance improvement methods
• Ability to make clear and effective public presentations about QI information, statistics, and performance improvement techniques

EDUCATION and/or EXPERIENCE:

Bachelor’s degree required.  Minimum of 2-year education, experience, or training in public health or health data analytics preferred.

Experience with use of Excel and data analytics is required; experience with Electronic Medical Records, and Azara (or other data analytics software) preferred.

CERTIFICATIONS:

CPR

LANGUAGE SKILLS:

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.  Ability to write routine reports and correspondence.  Ability to speak effectively before groups of customers or employees of the organization.  Bilingual (English and Medical Spanish) a plus.

MATHEMATICAL SKILLS:

Ability to use formulas and statistics, combine figures, and express numeric results as charts, tables, or other graphical elements. Calculate figures and amounts such as, interest, percentages, percent increase/decrease, average, standard deviation, and percentiles.  Ability to apply concepts of basic algebra and statistics.

REASONING ABILITY:

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.  Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

 PHYSICAL DEMANDS:

 The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  While performing the duties of this job, the employee is regularly required to talk or hear.  The employee frequently is required to stand and walk.  The employee is occasionally required to sit, use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; climb or balance, and stoop, kneel, crouch, or crawl.  The employee must occasionally lift and /or move up to 10 pounds.  Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORK ENVIRONMENT:

 The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.   The noise level in the work environment is usually quiet.  While performing the duties of this job, the employee will be exposed to carriers of contagious diseases. The employee may have to deal with irate and irrational clients who may or may not be under the influence of mind-altering substances such as cocaine, marijuana, alcohol, etc.