Michigan Trauma Quality Improvement Program (MTQIP) Reviewer Responsibilities:
Work closely with the Trauma Program Staff, including registrar, physicians, clinical staff and program manager to develop and implement standard practices, policies and procedures that support efficient capture of data.
Will be required to identify clinical quality improvement opportunities, participate in other special projects as requested by the coordinating center, resolve data discrepancies, and actively participate in site audits.
Graduate of an accredited School of Registered Nursing and currently registered in good standing with the State of Michigan.
Completed BA or BS degree in healthcare or business related field required. BSN preferred. For those hired into an RN position after January 1, 2015, it is required to obtain a BSN within 5 years of start date.
Minimum five years of experience including clinical nursing experience in an acute care setting required; trauma experience preferred.
Ability to proficiently create and utilize databases, word-processing, spreadsheets, presentation programs and other software relevant to the job. Requires technical knowledge of hospital applications data-query software spreadsheets and report-generating software. Internet skills and literature search capabilities required.
Self-directed; able to work effectively and efficiently with multiple interruptions and changing work priorities. Strong organizational and time management skills required. Able to make reliable independent decisions using analytical and problem solving skills. Demonstrates initiative and creativity in assigned work. Highly detailed and team oriented.
Provides administrative, technical, educational, and coordinating support to ensure effective, timely, hospital-wide quality assessment and performance improvement activities.
Under the direct supervision of the Trauma Program Manager and the Trauma Medical Director.
Collaborates with the Clinical Quality Department and/or the Director of Organizational Quality and Patient Safety to prepare required (regularly scheduled and ad hoc) reports to the Quality and Patient Safety Committees, Medical Staff committees, and Hospital Departments as appropriate.
May report directly to the VP of Quality and Safety, Medical Staff Leadership, and peer review/performance improvement committee leaders.
Supports the Mission, Vision, and Values of Munson Healthcare.
Embraces and supports the Performance Improvement philosophy of Munson Healthcare.
Promotes personal and patient safety.
Demonstrates effective customer service/interpersonal skills at all times.
a) Collaborates with leadership to identify and discuss performance improvement
strategies and opportunities as they relate to organizational mission, vision, and values,
clinical outcomes, and patient safety goals.
b) Analyzes and assesses clinical practices for opportunities to improve healthcare delivery.
Gains consensus as to performance improvement projects to be undertaken; assists in the
development and evaluation of standards, procedures, processes, and automated tools that
support established goals and regulatory requirements.
c) Serves on hospital, professional, and community committees as appropriate; provides
ongoing consultation and education for hospital policies, procedures and PI/Patient Safety programs/activities designed to meet regulatory and accrediting agency requirements (i.e. Joint Commission, CMS, IHI, DHHS, and Peer Review organizations).
e) Assists in identification of educational needs of medical and nursing staff through
participation in data registries and subsequent outcome analysis.
f) Assists in development and/or presentation of continuing education related to specific area
of interest/responsibility.
Supports physician sections/departments and peer review activities.
a) Assists the Trauma Program Manager and Trauma Medical Director with identifying cases to be discussed at the Trauma PIPS meeting monthly.
b) Coordinates and attends multi-disciplinary peer review meetings: tracking attendance, writing meeting minutes and submitting an annual report
c) Meets with Trauma Program Medical Director and Trauma Program Manager in support of medical staff performance improvement activities on a regular basis.
d) Assures confidentiality and integrity of all medical department performance improvement and peer review activities.