Manager Quality Improvement and Data Analytics
Company: St. Joseph Health
Location: Apple Valley
Posted on: May 3, 2021
Under the direction of the service area executive director
quality the Manager Quality Improvement and Data Analytics will be
responsible for planning, designing and directing performance
improvement work in alignment with the Value Triple Aim (Quality,
Service and Cost Excellence). The manager will coordinate and
develop the infrastructure and strategies to facilitate the
implementation of Performance Improvement and achievement of PSJH
goals, including integration of system-wide & ministry strategic
initiatives, and performance improvement strategies, projects, and
activities with system, region, and local ministry priorities in
coordination with quality and performance improvement leaders. They
ensures the proper preparation and coordination efforts to achieve
regulatory compliance with The Joint Commission and other
regulatory agencies for Quality Indicators.
The manager quality improvement and data analytics develops,
monitors and effectively regulates departmental budgets. Serves as
a catalyst and mentor for motivating productivity, innovation, high
employee morale and commitment to the organization.
Performs data analysis and develops/drives & executes innovative
strategies to achieve Quality, Service, & Strategic goals. Monitors
& reports ministry progress to executive leadership in PI &
Strategic Implementation. Develops, coordinates and implements
sustainability progress on improvement activities in collaboration
with improving performance leaders at the system, regional and
local ministry level.
Acts as primary resource to Service Line leaders to provide data
for decision making including VOA cost data, clinical outcomes,
LOS, payment data from payors, physician outcomes.
Provides outcomes for different payor designations, i.e., Blue
Distinction, Anthem Create monthly quality report for presentation
by Executive Lead by pulling most current data and working with
leaders for their input
Develops trend charts puling most appropriate data for all
Magnet outcomes related to clinical stories
In collaboration with care experience leader, provides Patient
Experience outcomes from Press Ganey related to overall outcomes
for hospital, units/departments, physicians
Supports Stroke service line support for Comprehensive Stroke
certification with support of RedCap tool for all Code Stroke data
and data flow into Quintiles and Joint Commission
Responsible for external data reporting: Cleans all errors in
data transmission file prior to upload to Premier. Enters Hip &
Knee abstractions and CSTK Stroke abstractions in Joint Commission
Reviews all CMS and JC data abstractions with Q Centrix team,
including stroke, hip & knee, and all other required quality
metrics. Reviews for fallouts and for accuracy.
Reviews all CMS readmissions with service line leads and
coordinate action plans with regional service area executive
director of quality.
Reviews mortalities >3 ROM score coordinate action plans with
regional service area executive director of quality.
Builds monthly and ad hoc reports in WEBI and AMALGA to review
trends for exec team and unit leaders.
Acts as hospital's QNET administrator - upload required
outcomes, i.e., CDAC validation outcomes. Downloads measure
outcomes, PEPPER reports, etc.
Maintains confidentiality of all information related to
patients, medical staff, employees, and as appropriate, other
Demonstrates service excellence and positive interpersonal
relations in dealing with others.
Facilitates the PI process throughout the organization acting as
a facilitator and mentor for department improvement teams.
Assures the standardization and consistency of quality
performance improvement activities throughout the organization.
Works collaboratively with regional service area Executive
Director Quality PI/Patient Safety/Accreditation leaders to develop
standardized processes and share "learnings" throughout the
community, region, and Providence Health and Services System.
Facilitates the establishment of organization monitoring and
evaluation of PI/patient safety activities using identified quality
Assists in the orientation and ongoing education of employees in
the quality performance improvement process in collaboration with
regional PI team.
Provides staff support for identified organization quality
committees/councils and service lines.
Interprets raw data and performs and/or facilitates comparative
analysis of clinical data.
Assists in the development, revision and evaluation of quality
improvement plans. Actively works with physician leadership,
directors and managers in the development and implementation of
quality performance improvement plans.
Keeps regional executive director quality, physicians and
management apprised of issues requiring actions and communicates
regularly about progress/trends toward key quality indicators.
Supervises the collection, assessment and presentation of
information to facilitate the ongoing measurement of processes and
Assists, as necessary, in the collection of data for the defined
Develops systems and processes to assure the reliability,
accuracy and confidentiality of information used in the department
Works collaboratively with Risk Management, Patient Safety, and
Regulatory on the integration of risk, patient safety, quality
improvement and regulatory compliance.
Collaborates with regional executive director of quality to
support Medical Staff leadership in the development and
implementation of systems and processes to identify practice
variations and opportunities for improvements in patient care
processes and/or outcomes for the organization.
Collaborates with regional executive director of quality and the
use of regional PI staff's use of the performance improvement
methodology to provide PI support to the organization.
Works collaboratively with the Accreditation and Licensure area
on ongoing survey readiness.
Provides comprehensive reports of quality performance
improvement activities to the PI teams and Medical Staff, Medical
Executive Committee, and the Medical Affairs Committee.
Serves as a coach and mentor to direct reports.
Maintains professional growth and development through
participation in seminars, educational programs, workshops, and
- Participates in medical staff, service line, organization
meetings as required.
Required education/experience for this position include:
Bachelor's Degree in a Health-related field.
At least 2 years of experience in an Acute care setting
practicing within specified licensure.
Demonstrated working knowledge of national healthcare trends in
quality improvement and management.
Working knowledge of The Joint Commission standards and/or
regulatory agency requirements regarding PI/Quality.
Success in working efficiently and effectively in a matrix
Ability to understand the needs and preferences of customers
Must possess strong presentation and interpersonal skills that
display a presence of leadership in a wide range of settings.
Skills: Quality and Safety / Driving improvement / Risk
Assessment / Conflict Resolution / Staff Development /
Interpersonal Communication /Must be organized, detail oriented and
like to work with statistics and evaluation of methodologies.
Efficiently problem solve, while dealing with a diverse set of
systems and individuals.
Ability in developing and motivating staff to their highest
potential, using strong leadership skills and interpersonal
Significant discretion and knowledge of department to prioritize
Respond to multiple duties simultaneously.
- Demonstrated expertise in healthcare data analytics with the
ability to take complex data sets, effectively data mine, and
through analysis identify pertinent insights an interpretation
providing actionable insights to drive quality improvement
Preferred education/experience for this position include:
Current California Registered Nurse License, or equivalent or
higher level licensure or equivalent experience and expertise in
quality data analytics strongly preferred.
Certified Professional in Healthcare Quality CPHQ, is strongly
- 3 years of Progressive hospital leadership positions.
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Keywords: St. Joseph Health, Apple Valley , Manager Quality Improvement and Data Analytics, Other , Apple Valley, California
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