Job Description
The **Clinical Quality Documentation Specialist I **reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.
The Clinical Quality Documentation Specialist I position facilitates improvement in the overall completeness and accuracy of quality data and outcomes through extensive interaction with physicians, nursing staff, interdisciplinary quality committees, multidisciplinary teams and clinical coders. The Clinical Quality Documentation Specialist I applies clinical expertise, knowledge of the national Quality agenda, professional nursing standards, current research, best practices, and interdisciplinary collaboration to advance problem analysis and creative process redesign for clinical documentation.
The Clinical Quality Documentation Specialist I acts as a change agent to systematically drive and implement change as prioritized by Clinical Documentation Leadership and Senior Clinical and Senior Quality leadership and/or through the quality and safety committees. Participates in performance improvement initiatives, receives and monitors control plans and data trends under the purview of the Clinical Documentation and Clinical Quality Programs and in collaboration with clinical interdisciplinary quality committees and physician practices. Key to this role is the ability to compel changes in documentation through in-person interaction to facilitate accurate representations of patient characteristics within the medical record so that process and outcome measures based on documentation reflect performance accurately.
Responsibilities:
- In partnership with Clinical Documentation Leadership and the Medical Directors of Clinical Documentation, maintains integrated relationships with business unit and system physician and administrative leaders to advance quality metrics through front-line documentation efforts.
- Rounds daily with physician and advanced practice providers (APPs) in assigned service line(s) or business units to ensure appropriate and accurate documentation in the medical record. Ensures the level of services and acuity of care will accurately be reflected in quality outcomes.
- Partners with operational and medical leadership in a given service line or business unit to identify, develop and implement successful communication and education, to engage physicians and improve processes and outcomes.
- Performs daily medical record reviews in assigned service line(s). Performs data collection activities to identify documentation issues, quality issues, and opportunities for improvement in patient care and services.
- Basic understanding of clinical documentation through the lens of local and national quality and ranking methodologies, including but not limited to, U.S. News and World Report, Vizient, Leapfrog, the CMS Star Rating, and payer contracts and assists the Managers of Clinical Documentation in execution of and maintenance of key strategies to effect change.
- Understands the basics of leveraging their NM network to initiate conversations, identify root causes and resolution, and align resources.
- Analyzes quality and patient safety data to identify patterns in the management of patient care and services using reported 1.) Hospital acquired conditions, 2) Patient safety indicators, 3) Case Mix index, and 4) Expected mortality.
- Collaborates with the Clinical Quality Team to model, teach and improve upon the culture of safety with shared improvement in all venues.
- Presents updates to operational and medical leadership, attending and resident physicians and interdisciplinary quality committees.
- Communicates effectively and collaborates with colleagues and the Clinical Coding Team. Fosters an environment to execute a shared vision in creating a model of best practice in the accurate reporting of patient diagnoses, comorbid conditions and treatment rendered.
- Professional Development and Education:
- Masters evidence and literature in relevant clinical area, discipline, and improvement science, including clinical quality improvement, patient safety, human factors, failure modes, root cause analysis, and related performance and safety resources.
- Applies knowledge of professional nursing standards, best practices, and interdisciplinary collaboration to advance problem analysis and resolution and creative process redesign.
- Other:
- Participates in a minimum of one NM Clinical Documentation committee as approved by Manager, Clinical Documentation
- Participates on departmental and hospital committees and task-forces as assigned.
- Participates in concurrent performance improvement activities and on-going review activities.
- Performs other job-related duties as requested, including special projects.
- Complies with Northwestern Memorial Hospital policies on patient confidentiality including HIPPA requirements and Personal Rules of Conduct.