Health Unit Coordinator-Burn Center

Criteria Based Job Description

Job Title: Medical Staff Services Project Date: August 2011 Manager Job Code: 725784 Reports to: Director of Medical Staff Services Department: Medical Staff Services Approved by: VP Medical Affairs

MINIMUM QUALIFICATIONS: Education: Bachelor’s degree required, preferably in business, quality management, nursing, statistics or related disciplines.

Experience: 3-5 years experience in quality management in a healthcare environment. 2 years project management experience and/or performance improvement.

Required Knowledge, Skills & Abilities:

 Ability to make independent decisions and use critical thinking skills  Familiar with quality management methods, measurement definition and analysis and project management (Lean, Six Sigma)  Ability to gather, analyze and interpret technical and clinical data  Ability to apply policies and principles to solve problems and deal with a variety of situations  Ability to manage multiple projects, analyzes and interprets data, and resolve complex problems  Ability to manage continuity of projects and initiatives  Ability to handle confidential information with discretion and in accordance with the Data Practices Act  Knowledge of medical legal issues, laws and regulatory agency requirements and standards  Ability to interpret and practice/support compliance with outside governing organizations such as the Joint Commission and Center for Medicare Services (CMS)  Ability to interpret departmental policies and procedures to Medical Staff members and other customers  Knowledge of Microsoft Office Suites and other Quality related software programs required in performing the tasks of Medical Staff Services

Preferred Knowledge, Skills & Abilities:

 Prefer demonstrated use of Decision Support system (DSS) software  Prefer demonstrated use of Project Management software

POSITION SUMMARY STATEMENT: 1 This position serves as the coordinator of quality focused metrics specifically for the medical staff services (MSS) department. This role will work with quality department for accumulating and compiling medical staff quality data to include gathering statistical data from various databases (HBI, HR, and EPIC) and compiling studies/reports on specific procedures and metrics. This role will review, analyze, interpret and provide recommendations for possible solutions for change to scorecards for providers. This role will also assist in identifying metrics. The primary focus on this role is to work with medical staff leadership on Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) process development, implementation and measurement. This role will manage all aspects of the projects for the Medical Staff Services department. Percentage MAJOR JOB DUTIES AND TASKS: Of Time: 1. Management of OPPE and FPPE Programs 70 a. Assist Medical Staff leadership in developing performance measures, data collection methods, data analysis and selection of improvement strategies for determining OPPE and FPPE information needs to support their areas of responsibility and overall hospital objectives. b. Identifies and provides information and analysis required for the decision making process in support of business operation c. Performs studies as they relate to specific procedures performed by specific groups of physicians and the related outcomes. d. Develop OPPE metrics to evaluate and monitor and determine the collection method or source for this data e. Generates the results of metrics, reviews, analyzes and provides interpretation of data results f. Supports the distribution of OPPE metrics via the Decision Support System (DSS) g. Update scorecards on timely basis utilizing HBI (Horizon Business Insight) system

2. Implements Quality Projects to Support Medical Staff Services (MSS) 10 Strategic Priorities a. Identifies improvement projects within MSS that provides support in implementation of MEC goals b. Collaborates with hospital Quality Department to implement quality initiatives c. Works with the Director or VPMA to identify the appropriate improvement methodologies (Lean, Six Sigma, PDSA) to achieve project goals d. Researches best practices, identification of changes and development of tests of change e. Establishes and maintains effective communications with medical staff f. Develops and maintains project documentation including work plans, progress on deliverables, barriers, risks and results reporting g. Collaborates with hospital quality staff on Process Improvement (P.I.). initiatives h. Compile statistical reports and graphs to reflect trending of medical staff quality data

3. Coordinates the Regulatory Requirements 10 a. Keeps abreast of external regulations including all federal, state and local laws and regulations pertaining to surgical services b. Reviews, evaluates and interprets regulations and works with leaders to ensure that processes, quality and results are consistent with compliance goals and objectives in support of company policies and applicable state and federal regulations. c. May assist with Joint Commission accreditation requirements and preparation as needed

4. Coordinates and Monitors Required Education, Training and 10 Performance Reviews for Providers 2 a. Familiar with all initial and annual training and education requirements needed for providers b. Coordinates and tracks continuing education program for all providers c. Provides new provider orientation d. Coordinates the process of the annual performance evaluations for section heads, division heads and medical directors e. Tracks results of medical staff peer reviews

5. Other duties as assigned

ORGANIZATIONAL EXPECTATIONS: 1. Promises to Patients and Families (and External Customers) * Treats patients, families and customers (external) with dignity, respect and compassion. * Provides accurate and timely information. * Actively listens and involves patients as they desire in their care. * Provides hassle-free access to services and needed care. * Anticipates needs and provides continuity and coordination of services. * Provides a safe, clean and healing environment. 2. Promises to each other – RESPECT Reliable. Dependable and follows through on responsibilities. Excellence. Goes above and beyond to make a positive difference each day. Show Appreciation. Values and acknowledges other’s contributions. Positive Attitude. Friendly, optimistic and helpful. Embrace Differences. Honors and learns from other’s uniqueness and experiences. Communicate. Listens, seek to understand and share information. Teamwork. Support others and together we all succeed. 3. Promises to Internal Customers * Genuinely express a can-do attitude in all of my interactions. * Proactive in my planning to ensure patients and external customer’s needs are met in a timely manner. Uses appropriate tools and process to solve problems. * Promotes a positive image of other departments to patients and co-workers. * Acts professionally and is accessible to other departments. * Recognizes every employee’s contributions to service patients and external customers. 4. Protect confidentiality 5. Maintains regular and timely attendance 6. Complies with safety instructions, observe safe work practices, provide input on safety issues and promote a safe work environment 7. Acts as a leader or participant in at least one Regions Patient Safety initiative. (This applies to positions that are involved in direct patient care as an example PCAs, transporters, ERTs).

AGE-SPECIFIC COMPETENCIES:

Yes X No Does this employee have direct patient contact? If yes, age- specific competency checklist MUST be attached.

3 LEADERSHIP RESPONSIBILITIES: None

PHYSICAL REQUIREMENTS: Long periods of sitting, intermittent walking for long periods (to various departments) Periodic lifting of paper supplies

ENVIRONMENTAL CONDITIONS: Normal shared office environment

EQUIPMENT: General office equipment: telephone, fax, computer, printer, copier etc.

______Contact Information: Debra Kelly Director, MSS Regions Hospital St. Paul, MN [email protected] 651-254-3861