This role partners with key stakeholder teams to implement reporting and quality improvement initiatives that support BSWH’s strategy to deliver high-quality, safe patient care and achieve performance excellence. The position ensures compliance with regulatory statutes, policies, and procedures while driving measurable improvements in patient safety and outcomes.
The ideal candidate brings experience in clinical data abstraction for regulatory quality programs, clinical registries (such as Get With the Guidelines), and/or retrospective clinical research studies. Familiarity with CMS IQR and OQR programs, as well as Joint Commission ORYX reporting requirements, is strongly preferred.
Experience with chart abstraction and/or process improvement initiatives related to Sepsis, Stroke, Perinatal Care, Get With the Guidelines, and/or eCQMs is highly desirable.
Essential FunctionsConduct concurrent and retrospective medical record reviews to investigate quality and patient safety concerns and identify performance improvement opportunities.Collect, abstract, and analyze data to support patient safety and quality improvement strategies in alignment with regulatory and entity-specific requirements.Support and facilitate quality and patient safety initiatives by developing action plans, analyzing outcomes, and implementing successful interventions.Develop and distribute routine and ad hoc reports to clinicians, administrators, medical staff committees, and corporate teams to ensure timely, accurate data for decision-making.Identify opportunities to enhance reporting processes, tools, and methodologies.Collaborate in the development and delivery of educational materials to increase awareness of quality and patient safety practices among staff and leadership.Apply quality improvement methodologies and tools, including proactive and retrospective risk assessments, to improve care delivery and patient perceptions of BSWH services.Research and share regional, system-wide, and industry best practices with leadership and team members.Participate in quality improvement teams, unit and facility huddles, and the ZERO Harm rounding process as directed by leadership.Serve as a subject matter expert by providing comprehensive measurement analysis for quality improvement initiatives across the organization.Maintain current knowledge of emerging trends and advancements in quality reporting and analysis through continuing education, professional organizations, and industry resources.Key Success FactorsAdvanced knowledge of quality and performance improvement methodologies, evidence-based patient safety practices, outcomes management, and regulatory environments.Strong understanding of Texas regulations, Joint Commission, and CMS standards.Strong verbal, written, and interpersonal communication skills.Proficiency with computers and related software applications.Ability to establish and maintain collaborative working relationships across departments.Ability to facilitate quality and patient safety initiatives effectively.Skilled in data collection, abstraction, analysis, and report preparation.Ability to educate healthcare providers on quality and patient safety topics based on data, industry standards, and regulatory requirements.Strong organizational skills with the ability to prioritize tasks and meet deadlines.Licensed clinician (e.g., RN, PT, OT, Dietitian, Respiratory Therapist) preferred.QualificationsEducation: Bachelor’s degree required, or four additional years of relevant work experience above the minimum qualification.Experience: Minimum of three (3) years of related experience in quality improvement, clinical data abstraction, reporting, or patient safety.
BENEFITS
Our competitive benefits package includes the following
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level
- EDUCATION - Bachelor's or 4 years of work experience above the minimum qualification
- EXPERIENCE - 3 Years of Experience