Stroke Quality Coordinator Senior Intermediate

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Mission Statement

Michigan Medicine improves the health of patients, populations and communities through excellence in education, patient care, community service, research and technology development, and through leadership activities in Michigan, nationally and internationally. Our mission is guided by our Strategic Principles and has three critical components; patient care, education and research that together enhance our contribution to society.

Job Summary

Stroke is the fifth leading cause of death in Michigan. In order to care for patients suffering from this critically important disease, Michigan Medicine is home to a Joint Commission Certified Comprehensive Stroke Center.

The Stroke Quality Coordinator works with the remarkable clinical faculty and staff to ensure that Michigan Medicine patients receive the highest quality stroke care available, and to continue to improve on the excellent care that is already present.

The Department of Neurology seeks a Stroke Quality Coordinator to assist with the development and management of the quality metric monitoring required to achieve and maintain certification. This includes, but is not limited to all data elements for certification by the Joint Commission such as:

• Compliance monitoring for The Joint Commission (TJC) Primary Stroke Center and CSC core measures and requirements,
• Centers for Medicare and Medicaid Services (CMS) quality reporting requirements metrics
• American Heart Association Get With the Guidelines Quality Measures (AHA-GWTG) and
• UMHS internal quality improvement data for initiatives such as Stroke Arrival Process metrics as well as patient satisfaction, clinical outcomes, safety, efficiency metrics, activity data and other data as requested.

The clinical analyst helps facilitate process improvement, coordinate improvement plans for the stroke program and guide diverse groups to reach consensus regarding appropriate interventions.

The clinical analyst will abstract, merge, manage, and prepare compliance and quality data in the form of useful information to aid analysis by CSC Leadership (Chairs, Directors, and Manager) who, with this information, can enhance the quality of clinical care for the stroke patients.

Responsibilities*

• Chart Abstraction and Audits: Develops and maintains tracking method for concurrent review of stroke patients to ensure compliance with all quality metrics. Performs accurate and timely data abstraction including but not limited to data for CMS, TJC, GWTG, QA initiatives, and the internal Stroke Log. Review all IV TNK and endovascular intervention cases to ensure protocols were followed; research details when problems arise, present case to Leadership. Maintains knowledge of measure specifications and data definitions necessary to complete this work. Participates in or leads inter-rater reliability sessions to ensure abstraction accuracy and success in external agency validation. Provides training to other team members and serves as a resource for data abstraction requirements, ensuring reliability and validity of data.
• Data Management: Works with data from many different clinical and administrative sources (internal and external to the UM-CSC) and has expertise to abstract, merge, manage, and prepare the data in the form of useful information to aid in analysis. Creation and maintenance of program specific patient satisfaction data as requirement by TJC, assessing and communicating trends for CSC leadership to determine correct interventions to reduce readmission rates and manage patient needs in correct level of care setting (e.g. outpatient clinic).
• MiChart/HITS/Vendor Liaison: Collaborates with MiChart and HITS teams to optimize documentation efforts for clinicians, building of reports used for monitoring quality measurements and process improvement activities. Assists the team in creating crosswalks/uploads to external vendors utilized by the institution for reporting to external regulatory agencies. Troubleshoots any functionality issues with vendor products.
• Data Review and Quality Improvement Support: Thoroughly reviews clinical metric performance, assess for trends and underlying causes for deficiencies for escalation and review by the CSC Program Manager. Participates in a CSC quality, stroke arrival, and peer review meetings to support the data analytic portion of the process. Attends morbidity and mortality conferences for neurology, neurosurgery, neurointerventional radiology, and vascular surgery to ensure compliance with the monitoring and review of complication and mortality data as required for CSC programs. Monitor changes in laws, regulations and policies (specifically in the federal registrar that impact performance measurement and reimbursement) and assure compliance with reporting procedures and work flows.
• Reporting: Expertly produces all internal and external performance reports which include but are not limited to Stroke Core Measures, Stroke GWTG, Stroke Arrival, Peer Review, Comprehensive Stroke Measures, and CSC program specific elements that assist the CSC leadership in managing quality patient care to stroke patients as well as the program overall. Creation and maintenance of a real time dashboard for clinicians to utilize in increasing performance of our quality metrics for delivering interventions (IV TNK and endovascular therapies) to stroke patients. Provides reports for ad hoc meetings to address specific areas of deficiency. Maintains all databases for the CSC program and responds to requests by providers for data for research purposes. Provides training for report creation and serves as a resource for other team members, ensuring reports meet the standards of timely, discernible, reliable, meaningful, and actionable.
• On-Site Review: In collaboration with the CSC Program Manager, provide guidance and assistance in preparation for on-site surveys for TJC, as well as follow-up for areas of performance requiring attention identified during the survey. Aids the CSC Program Manager in the creation and distribution of tools and educational materials to improve understanding of and meet TJC requirements and expectations. Is available onsite, and in the 7 business days prior to, and during the TJC survey. Additionally, they are available onsite, and in the 7 business days prior to, and during the intra-cycle call.
• Education: Provide education references to clinicians (physicians, nurses, APN/PA, etc.) related to clinical metric performance requirements within CSC.
• Process Improvement/Joint Commission Compliance: In collaboration with the CSC directors, program manager, and other CSC team members, identifies areas of opportunities and conducts team meetings; recommend and evaluate processes to improve systems and patient care across the continuum of care; responsible for coordinating the efforts with team members for the development of performance improvement and action plans. Serves as subject matter expert for stroke center certification in response to inquiries from other departments such as emergency medicine, neurology, neurosurgery, vascular surgery, neurointerventional radiology, PT, OT, SLP, nursing units, etc.
• Provides support to CSC physician directors and program manager in design and delivery of care management of stroke patients: With physician leadership and program manager: Review and monitor care for the stroke population; review and revise provider ordersets, treatment guidelines, etc. and ensure alignment between the various protocols and ordersets that impact stroke patient care; reviews and maintains policies and procedures specific to the CSC.
• Participates in, coordinates and convenes CSC Standing & Ad Hoc Meetings: Chair or co-chair committees as assigned. Create agendas, produce meeting minutes, assign action items, and follow-up on tasks assigned.
• Other duties as assigned.

Required Qualifications*

• Senior level will require a minimum of a bachelor's degree in a recognized field which is directly related to the duties of this position, and a minimum of 5-8 years of experience in analyzing and interpreting process, clinical outcomes or cost of care.
• Intermediate level will require a minimum of a bachelor's degree in a recognized field which is directly related to the duties of this position, and a minimum of 3 years of experience in analyzing and interpreting process, clinical outcomes or cost of care.
• Demonstrated expertise in health information management: analyzing and interpreting data in a health care-related field; providing education to clinicians; and lead role in process improvement activities.
• Experience with data management, analysis, and visualization tools such as Excel, SPSS, SAS, Tableau, etc.
• Experience in creating and disseminating discernible, reliable, meaningful, and actionable data; experience in establishing, implementing, and analyzing interventions to improve process and outcome quality measures
• Broad understanding of health care and/or health policy terminology and the understanding of procedures and health care settings
• Demonstrates critical thinking and analytical skills to understand root cause issues and how best to display information that is useful in creating opportunities for clinical improvement.
• Excellent organizational skills in setting priorities and balancing multiple priorities and demonstrated follow through bringing tasks to closure with acceptable outcomes.
• Excellent interpersonal, written and verbal communication skills with an emphasis on customer service.
• Ability to work independently with minimal supervision and maximum collaboration in a team environment.
• Ability to work with a diverse group of people in a diplomatic and effective manner with demonstrated problem solving and conflict resolution skills.
• Demonstrated commitment to enhancing work place culture, embracing diversity and a commitment to creating the ideal work environment for faculty and staff.
• Knowledge of University policies, rules and regulations, and professional knowledge is required.

Desired Qualifications*

• Background in cerebrovascular disease/stroke care or prior experience with processes and workflows in an inpatient setting is strongly desired.
• Experience with The Joint Commission Primary and/or Comprehensive Stroke Center certification (Disease Specific Care Certification).
• Experience with Stroke Core Measures and/or Stroke Get with the Guidelines abstraction and reporting.
• Experience in clinical process improvement
• Experience in clinical quality, safety and management work
• Lean or Six Sigma methodology experience
• Ability to simultaneously oversee multiple projects
• Knowledge of Epic electronic medical record system

Modes of Work

Positions that are eligible for hybrid or mobile/remote work mode are at the discretion of the hiring department. Work agreements are reviewed annually at a minimum and are subject to change at any time, and for any reason, throughout the course of employment. Learn more about the work modes.

Work Locations

This position is required to be able to seamlessly navigate through different physical areas of a large, mutli-building hospital and to be physically present during the Joint Commission Survey. Outside of the navigation and presence requirements for the survey, periods of remote work may be possible where appropriate to the task and role.

Underfill Statement

This position may be underfilled at a lower classification depending on the qualifications of the selected candidate.

Additional Information

Supervision Received

Direct supervision is received from the CSC Program Manager.

Background Screening

Michigan Medicine conducts background screening and pre-employment drug testing on job candidates upon acceptance of a contingent job offer and may use a third party administrator to conduct background screenings. Background screenings are performed in compliance with the Fair Credit Report Act. Pre-employment drug testing applies to all selected candidates, including new or additional faculty and staff appointments, as well as transfers from other U-M campuses.

Application Deadline

Job openings are posted for a minimum of seven calendar days. The review and selection process may begin as early as the eighth day after posting. This opening may be removed from posting boards and filled any time after the minimum posting period has ended.

U-M EEO Statement

The University of Michigan is an Equal Opportunity Employer. We are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants, including protected veterans and individuals with disabilities.