Job Number:

LOCATION/DEPT.: John H Stroger Hospital/Trauma & Burn, Chicago, IL

SHIFT: Days

JOB SUMMARY

The Clinical Performance Improvement Analyst is responsible for the development, implementation, and maintenance of the department's performance improvement program for Trauma department. Measures, analyzes and facilitates improvement in clinical performance and outcomes. Provides direction and oversight of quality metric reporting. Identifies key clinical quality and patient safety measures. Uses the results of quality improvement activities to initiate change in patient care practices within the Trauma department.

TYPICAL DUTIES

• Develop the indicators of performance and conduct audits reporting results.
• Conducts audits by visual inspection and by collection and analysis of data to determine compliance with regulatory, accrediting and clinical practice standards and reports on trends indicative of the quality of services rendered in collaboration with the Trauma Program Coordinator.
• Submits reports on regulatory mandated and/or program specific quality metrics.
• Identifies and recommends methodologies, actions, and/or modifications to provide structural clinical and system process for improvement.
• Develops audit tools and establishes measure of performance.
• Responsible for the review and development of recurring reports and practices to promote continuous quality improvement.
• Develops methods and tools to be utilized by staff for monitoring quality and appropriateness of patient care on an ongoing basis.
• Monitors the Trauma Service Registry database, identifying Pl (performance improvement) trends.
• Analyzes trauma data to provide both scheduled and ad hoc reports.
• Integrates audit findings into training necessary to overcome performance deficiencies.
• Works with Information Technology Department to develop a process the enables the creation of reports from the current electronic medical record systems.
• Maintain the efficient operation of the trauma PIPS (performance improvement and patient safety) process.
• Supports Performance Improvement Plans and special projects and assists with staff education.
• Attends daily morning rounds, clinical rounds, ongoing meetings and trainings at various locations and brings the information back to share and/or implement in quality and access to care.
• Remains current with knowledge of current trauma trends and developments by reading appropriate literature and attending related seminars, conferences, and other educational offerings as related to database management and PIPS
• Acts as quality liaison with transferring facilities to provide patient feedback and identify areas for process improvement.
• Performs other duties as assigned.

MINIMUM QUALIFICATIONS

• Licensed as a Registered Professional Nurse in the State of Illinois, required.
• Bachelor's degree in Nursing, required. (Must provide official transcripts at time of interview)
• a minimum of three (3) years of experience working to support quality improvement at a hospital or health system, required.
• Knowledge of issues affecting the delivery of healthcare services, is required.
• Prior experience working with Electronic Medical Record is required.
• Prior experience working with national quality programs (i.e. TQIP, NSQIP, NTDB, etc.) is required.
• Prior experience working with trauma registry and/or database management is required.
• Advanced Trauma certification in one of the following: Trauma Nurse Core Course (TNCC), Trauma Nurse Specialist (TNS), Trauma Certified Registered Nurse (TCRN) is required.
• Proficient in Microsoft Word, PowerPoint and Excel, required. (Testing may be required)

PREFERRED QUALIFICATIONS

• Recent ER/Trauma clinical experience, preferred.
• Healthcare Quality Management certification, preferred.
• Pre-hospital experience, preferred.
• Formal quality training and certification, preferred.
• Bilingual, preferred.

KNOWLEDGE, SKILLS, ABILITIES AND OTHER CHARACTERISTICS

• Knowledge and operational experience in regulatory, safety, care management and related fields
• Knowledge of HIPAA and principles of confidentiality
• Excellent verbal and written communication skills necessary to communicate with all levels of staff and a patient population composed of diverse cultures and age groups
• Strong project management skills
• Skill in the use of Microsoft Office and EMR
• Ability to prioritize, plan, and organize projects and tasks
• Ability to adhere to department policies and standards utilizing best practices
• Ability to maintain a professional demeanor and composure when challenged
• Ability to function autonomously and as a team member in a multidisciplinary team
• Demonstrate attention to detail, accuracy, and precision
• Demonstrate analytical and organizational , problem-solving, critical thinking, time management and conflict resolution skills

VETERAN PREFERENCE

PLEASE READ

When applying for employment with the Cook County Health & Hospitals System, preference is given to honorably discharged Veterans who have served in the Armed Forces of the United States for not less than 6 months of continuous service

To take advantage of this preference a Veteran must:

• Meet the minimum qualifications for the position.

• Identify self as a Veteran on the employment application by answering yes to the question by answering yes to the question, "Are you a Military Veteran?"

• Attach a copy of their DD 214, DD 215 or NGB 22 (Notice of Separation at time of application filing. Please note: If you have multiple DD214s, 215s, or NGB 22S, Please submit the one with the latest date. Coast Guard must submit a certified copy of the military separation from either the Department of Transportation (Before 9/11) or the Department of Homeland Security (After 9/11). Discharge papers must list and Honorable Discharge Status. Discharge papers not listing an Honorable Discharge Status are not acceptable

OR

• A copy of a valid State ID Card or Driver's License which identifies the holder of the ID as a Veteran, may also be attached to the application at time of filing.

If items are not attached, you will not be eligible for Veteran Preference

VETERANS MUST PROVIDE ORIGINAL APPLICABLE DISCHARGE PAPERS OR APPLICABLE STATE ID CARD OR DRIVER'S LICENSE AT TIME OF INTERVIEW.

Benefits Package

• Medical, Dental, and Vision Coverage
• Basic Term Life Insurance
• Pension Plan and Deferred Compensation Program
• Employee Assistance Program
• Paid Holidays, Vacation, and Sick Time
• You may also qualify for the Public Service Loan Forgiveness Program (PSLF)

For further information on our excellent benefits package, please click on the following link: http://www.cookcountyrisk.com/

MUST MEET ALL REQUIRED QUALIFICATIONS AT TIME OF APPLICATION FILING

Degrees awarded outside of the United States with the exception of those awarded in one of the United States' territories and Canada must be credentialed by an approved U.S. credential evaluation service belonging to the National Association of Credential Evaluation Services (NACES) or the Association of International Credential Evaluators (AICE). Original credentialing documents must be presented at time of interview.

*Please note all offers of Employment are contingent upon the following conditions: satisfactory professional & employment references, healthcare and criminal background checks, appropriate licensure/certifications and the successful completion of a physical and pre-employment drug screen.

*CCH is strictly prohibited from conditioning, basing or knowingly prejudicing or affecting any term or aspect of County employment or hiring upon or because of any political reason or factor.

COOK COUNTY HEALTH AND HOSPITALS SYSTEM IS AN EQUAL OPPORTUNITY EMPLOYER