Clinical Quality Improvement Specialist is a position within the Quality Resources Department and Transformation Division of Billings Clinic. The Clinical Quality Improvement Specialist serves as a subject matter expert regarding clinical quality measures and outcomes of care. The subject matters include clinical quality surveillance and compliance, hospital acquired conditions, patient safety indicators, and surgical improvements indicators. The Clinical Quality Improvement Specialist provides consultative services focused on providing the highest quality and safest care to patients while decreasing risk to the organization. Scope of work includes acute care hospital, ambulatory clinics, branch clinic locations, ambulatory surgery center, and fully owned and affiliated regional facilities. The position reports to the Director of Quality Resources and assumes responsibility for one or more of the of the following functions: 1. Clinical quality measures 2. Hospital acquired conditions 3. Patient safety indicators 4. Mortality reviews 5. Surgical improvement programs 6. Quality improvement projects

Essential Job Functions
• Supports quality activities and practices through utilizing the knowledge of clinical quality outcomes data, prevention and control science, process improvement principles, high reliability organizing, behavioral sciences, and quality standards for improving patient care and services.
• Effectively builds and maintains relationships with colleagues from key departments, including infection prevention and patient safety, pharmacy, nursing, nursing quality, nursing leadership, surgery leadership, sterile processing, medical staff, risk management, materials management, volunteer services, human resources, organizational development, professional development, operational leaders, executive management, and other stakeholders through positive interaction, problem identification, and resolution.
• Reviews, analyzes, and applies existing regulations, standards, guidelines of applicable professional organizations and governmental agencies. Integrates regulatory requirements and current clinical quality measure specifications into organizational standards and practices.
• Reviews, analyzes, and applies pertinent information from current scientific literature and publications. Integrates relevant public health issues into practice.
• Assists in the development of methodologies to fulfill the organization’s strategic initiatives for clinical quality outcomes improvement and required regulatory reporting.
• Educates and assists medical, nursing, and other clinical staff, management, and senior executive leadership, in identifying and capitalizing upon opportunities for improvement and facilitates cross-functional team development, when appropriate.
• Standardizes processes to optimize learning from medical record chart abstractions, clinical outcomes data, and clinical quality risk assessments.
• Assists in the development of clinical quality education for in-service programs to departments.
• Assists with goal setting to improve performance in clinical quality outcome measures.
• Conducts surveillance activities by using current clinical quality measure specifications for hospital acquired conditions, patient safety indicators, clinical quality measures, and surgical improvement programs.
• Reviews pertinent clinical information including treatments, procedures, related diagnostic tests and clinical notes to determine if cases meet surveillance definitions for hospital acquired conditions, patient safety indicators, and sepsis. Performs analysis of findings and disseminates key findings to providers to improve performance.
• Reviews pertinent clinical information including treatments, procedures, related diagnostic tests and clinical notes to determine quality outcomes. Performs analysis of findings and disseminates key findings to providers to improve performance.
• Identifies clinical quality processes. Interprets the relevance of diagnostic and laboratory reports and correlates clinical signs and symptoms with various clinical care outcomes and processes.
• Initiates investigations when unusual clinical quality outcomes are observed. Summarizes findings, reports findings to healthcare personnel, leadership for corrective action. Conducts investigations when indicated and assists in designing and promoting interventions targeted at improving clinical quality outcomes.
• Maintains accurate record of hospital acquired conditions, patient safety indicators, surgical improvement registries, and clinical quality measures data within software systems.
• Assures accuracy of hospital acquired conditions, patient safety indicators, surgical improvement registries, and clinical quality measures data entry into program software and meets deadlines for reporting.
• Prepares regular reports appropriate to the recipients.
• Provides routine and custom reports to nursing, medical staff, oversight committees, operational leaders, executive leaders, and governing board.
• Assists in preparing an Annual Quality Resources Report.
• Develops and revises system-wide quality policies and procedures.
• Demonstrates understanding of regulatory and advisory guidelines through application.
• Reviews, analyzes, and implements regulations, standards, or guidelines of applicable governmental agencies, accreditation bodies, and professional organizations.
• Conducts activities to maintain continuous preparedness for periodic and annual accreditation surveys.
• Provides feedback to regulatory, advisory, and accrediting agencies regarding opportunities for improvement in standards and regulations.
• Cooperates and collaborates with Risk Management for both risk prevention measures and clinical event investigation.
• Provides support to Risk Management for resolution of clinical care complaints and issues related to the quality of patient care and services.
• Demonstrates understanding of high reliability organizing (HRO) principles through use of Universal Skills and behaviors that promote quality and safety for both patients and employees.
• Utilizes HRO Universal Skills in daily work.