Clinical Quality Leader II

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POST DATE 9/10/2016
END DATE 7/19/2017

Northwestern Memorial Healthcare Winfield, IL

Winfield, IL
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Mid-Career (2 - 15 years)
Bachelors Degree


Core Responsibilities:

Plan, develop and manage the hospital's efforts for comprehensive Physician Peer Review, and Physician/APN/PA OPPE and FPPE. Collaborates with various Medical Directors and clinical chairpersons to develop, implement and manage a process that collects and analyzes clinical and outcome data which is used for performance improvement initiatives and in the credentialing and privileging processes. The incumbent will work with highly confidential and sensitive clinical information and will maintains the compliance with the Illinois Medical Studies ACT (735 ILCS 5/8-2101). This position requires unique insight and knowledge of clinical medicine. Specific job responsibilities include:

* Manage and plan the hospitals effort in implementing and maintaining the Physician Peer Review process, which will drive improvement in the areas of quality and safety

* Collaborates with Physician leaders in developing appropriate quality indicators by department, to be used in Physician Performance Improvement and Physician Feedback Report

* Manage and oversee appropriate database systems that provide a comprehensive repository of Peer Review/quality

* Provide timely and specific communication to the committee/appropriate medical staff, and prepare reports for MEC and quality committees as indicated

* Communicate regularly with Chief Medical Officer on the status and results of all Peer Review programs and projects

* Maintain current knowledge of the Medical Staff organizational manual as it applies to the peer review process

Additional Responsibilities:

Significant independence and autonomy in collaboration with department or service based committees as well as cross-departmental and hospital-wide initiatives. Participate as a change agent to systematically drive and implement change as prioritized by senior clinical leadership and quality / patient safety committees. Bring leadership and communication skills to interdisciplinary quality/patient safety efforts. Lead the planning, implementation and monitoring of the NMH Quality Plan in clinical interdisciplinary areas as assigned. Take leadership on peer review (as assigned) in collaboration with clinical colleagues and leadership. Take initiative and lead the development of plans in collaboration with clinical colleagues in multiple departments and disciplines convene, educate, facilitate consensus. Research and develop quality measurement, evaluation and improvement approaches demonstrate significant knowledge of current and future trends in quality measurement. Prepare assessments and recommendations for hospital-wide and senior committees. Contribute to organizational learning and dissemination through publication, presentation, collaboration with clinical colleagues on these efforts. Provide mentoring and coordination for designated efforts of other staff in the department and beyond, as well as students/interns as relevant. Work with external agencies such as QIO and payors on quality issues.
Knowledge/Expertise: Maintain familiarity with the core literature and resources, and national, state and local regulatory and accreditation requirements, e.g. those related to clinical quality improvement, patient safety, human factors, failure modes, root cause analysis, and related performance and safety resources. Apply professional clinical knowledge and other clinical standards, best practices, and interdisciplinary collaboration, relevant to assigned clinical area, to advance problem analysis and resolution and creative process redesign. Integrate and innovate tools to promote standardized evidence-based clinical practice as appropriate (i.e., standardized order sets). Facilitate the use of quality management principles and performance improvement tools. External: Assist clinical teams and leadership to respond to quality-related queries from external constituencies: patients, families, payers, media, researchers, etc. Assure compliance with relevant quality / process improvement regulatory and accreditation requirements Master relevant clinical, quality measurement, patient safety and measurement as pertinent to assigned clinical area. EOE Minorities/Women/Disabled/Veterans. VEVRAA Federal Contractor.

* Bachelors degree in Nursing or an Allied Health profession.

* Eight or more years of recent experience in the acute or medical practice care setting and/or quality management/improvement organizations as relevant to targeted assignments.

* Certified Professional in Healthcare Quality (CPHQ) or Certified Professional in Patient Safety (CPPS) required within one year.

* Clinical experience.

* Quality management and improvement experience.

* Advanced competence with Excel and data analysis.

* Highly effective and experienced at facilitation of teams including complex multi-disciplinary projects.

* Knowledgeable and skilled at managing disparate perspectives and conflict.

* Excellent writing and presentation skills.

* Medical record review/abstraction experience.

* Working knowledge of performance improvement methodologies (i.e. DMAIC), analytic tools and methods, familiarity with basic statistics as related to healthcare quality.

* Experience with implementation of quality/patient safety improvement.

* Relevant computer skills (Excel, PowerPoint, Word, electronic medical records, clinical databases).

* Excellent leadership, facilitation, and communication (oral, written) skills.

* Exceptionally strong interdisciplinary collaboration skills are needed.


* Masters degree strongly preferred.

* Evidence of advanced commitment to profession.

* Knowledge of guidelines, healthcare standards, and regulations.

* Experience with clinical outcomes, safety, and patient satisfaction data.

* Evidence of publishable work (research, quality reports, clinical summaries).