Position Summary
Responsible for the collecting, organizing, analyzing and presenting data about the hospital's performance in order to provide statistically valid information that will improve overall performance. Facilitates performance improvement activities and CQI activities throughout the facility. Acts as a resource person to administrative team, department managers and medical staff. Assists with all regulatory body surveys; Joint Commission, State Licensing Review, CMS Validation Surveys, etc. Performs other duties as assigned.

Responsibilities:

Effectively collects and aggregates data.
Effectively performs accurate statistical analysis and compilation of reports to facilitate data review.
Collects, analyzes and compiles reports from individual incident reports and occurrence information to allow for priority processing of performance improvement activities.
Able to review and analyze internal data reports, reports from external sources, i.e., Joint Commission sentinel event report information, Core Measure performance measures, occurrence reporting information from state and federal sources and current literature.
Works in conjunction with the Performance Improvement Director, management, reviews and analyzes data to assist with presentation of data that allows for risk analysis and assessed progress toward stated goals.
Is a reporting member of the Performance Improvement Committee on data findings, actions and monitoring. Is present at committee to serve as a data resource individual. Supports the Performance Improvement/Patient Safety Committee meetings by collecting and formulating relevant information in such a way that decision making is facilitated.
Reviews sentinel events and near miss occurrences and assists with data preparation for root cause analysis.
Maintains control of data/database related to the facility's performance improvement program, however reports to the Performance Improvement Director for administrative control.
Provides timely reports that summarize the results of performance improvement programs; assesses the effectiveness and quality of said programs, redesigned processes.
Prepares statistical reports as requested.
Formats PI data in charts and/or graphs with accompanying analysis, summary and findings.
Assists with preparation for all regulatory surveys; Joint Commission, State Licensing Review, CMS Validation Surveys, etc.

Position Requirements:
Licensure/Certification/Registration:
Registered Nurse license in State of Oklahoma required.

Education:

High school education or equivalent. Associate degree in nursing required. BSN preferred.

Experience:
Minimum of two years healthcare experience required.
Course work in statistics, data analysis, data management and presentation of processes preferred.
Additional course work in performance improvement and CQI preferred.
Previous experience in performance improvement activities preferred.

Special qualifications:
Must possess knowledge of Joint Commission and other accrediting agency standards. Must possess effective verbal, written and presentation skills. Must have adequate typing and basic computer skills. Ability to work in a fast paced environment with frequent interruptions. Must be able to manage multiple deadlines. Must be able to problem solve and make decisions with moderate supervision.

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