Coordinate all data analysis functions for EPCH Quality Management. Work under the direction of the Director of Quality Management to ensure compliance with regulatory agencies. Assist in evaluating and preparing data for retrieval and preparation of data for submission. Perform duties within approved practices and exercises independent judgment within pre-determined guidelines. Assesses, organizes and synthesizes clinical data collected for a specific purpose and/or for individuals/agencies requiring such information. In addition, ensure that data produce valid, meaningful, and reliable results. Proactively supports the efforts that ensure delivery of safe quality patient care.

Serves as an internal consultant on quality data and provides education to the clinical leaders and employees and helps to ensure Joint Commission compliance. Works with Clinical Leaders and Employees to problem solve and determine satisfactory solutions achieving compliance, or developing suitable alternatives that will meet regulatory requirements aligned with El Paso Children’s Hospital’s mission and values.

Required Skills

1. Ability to apply knowledge of TJC, CMS, and regulatory accrediting agency standards to assure compliance.

2. Knowledge of Joint Commission Standards, CMS Standards and Core Measures, NDNI Criteria and Measures.

3. Ability to communicate effectively; written and verbal skills required.

4. Ability to understand, use and teach the principles of performance improvement and quality.

5. Ability to evaluate quality issues and present data to other professionals in a clear concise manner.

6. Proficient in utilizing the principals of analytical assessment and creative problem solving.

7. Knowledge of hospital systems and organizational relationships.

8. Ability to use critical thinking skills to conduct research and utilize interpersonal and problem-solving skills.

9. Ability to organize, delegate, implement, and evaluate effectiveness of processes.

10. Ability to interview and work in teams.

11. Ability to use a computer and related software applications.

Required Experience

Work Experience:

Minimum of two years of experience in healthcare preferred, with knowledge of Joint Commission activities and/or quality improvement, required.

License/Certification:

Registered Nurse in the state of Texas preferred.

Education:

Bachelor’s degree in Nursing or Healthcare related field required. Master’s degree preferred.

1. Ability to apply knowledge of TJC, CMS, and regulatory accrediting agency standards to assure compliance.

2. Knowledge of Joint Commission Standards, CMS Standards and Core Measures, NDNI Criteria and Measures.

3. Ability to communicate effectively; written and verbal skills required.

4. Ability to understand, use and teach the principles of performance improvement and quality.

5. Ability to evaluate quality issues and present data to other professionals in a clear concise manner.

6. Proficient in utilizing the principals of analytical assessment and creative problem solving.

7. Knowledge of hospital systems and organizational relationships.

8. Ability to use critical thinking skills to conduct research and utilize interpersonal and problem-solving skills.

9. Ability to organize, delegate, implement, and evaluate effectiveness of processes.

10. Ability to interview and work in teams.

11. Ability to use a computer and related software applications.