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Quality Improvement Research Analyst

Job Summary

The Quality Improvement Research Analyst is responsible for overseeing all activities specific to the following programs: the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), the Collaborative Endocrine Surgery Quality Improvement Program (CESQIP), and the Vascular Quality Initiative (VQI). The Quality Monitoring Analyst’s chief responsibility is to collect and submit reliable data to the MBSAQIP (American College of Surgeons), CESQIP (Society for Endocrine Surgeons), and VQI programs (Society for Vascular Surgeons). This is accomplished through high-quality clinical screening, data compilation, documentation, and entry of data into the applicable databases for all eligible surgeries at The Mount Sinai Medical Center. The Quality Monitoring Analyst also works closely with the members of the Department of Surgery to identify opportunities for clinical quality improvement and other initiatives, as identified.

Duties and Responsibilities

1. Data Collection
  • Responsible for the identification of surgical patients for inclusion in each program registry through the application of strict program inclusion/exclusion criteria.
  • Responsible for the reliable collection of pre-operative, operative, and post-operative data components for the program through the effective utilization of the hospital electronic medical record system.
  • Responsible for ensuring complete data and 100 percent case entry for all applicable case types and surgeons accrual per year.
  • Compiles applicable data and prepares presentation of data for quarterly bariatric surgery morbidity and mortality conferences, in addition to data for semi-annual meetings across the health system.
  • Compiles applicable data and prepares presentation of data for vascular surgery morbidity and mortality conferences.
  • Communicates with surgeons and surgical teams to ensure reliable data collection of procedures and all postoperative occurrences.
  • Responsible for identifying areas for streamlining and process improvement in the data collection process.
  • Demonstrates appropriate utilization of resources necessary to obtain valid, reliable data for entry into the Program.

2. Website Interaction
  • Responsible for keeping abreast (and communicating to appropriate personnel) applicable changes in the MBSAQIP, CESQIP, and VQI programs, policies, and data entry requirements.
  • Responsible for utilizing software applications available from the MBSAQIP, CESQIP, and VQI programs for timely data collection, entry, and analysis.
  • Responsible for monitoring, accessing, and compiling the data and quality/benchmark reports from the program websites for use in quality improvement projects.

3. Working Effectively with Patients, Families, and Staff
  • Establishes effective working relationships with members of the hospital community, especially staff in the Surgery, Medicine, Nursing, Medical Records and the Information Systems departments whose support is necessary for the management and success of the quality programs.
  • Maintains communication with clinical staff regarding the contact of patients via telephone and/or written communications post-operatively, as applicable for the purpose of identifying possible occurrences associated with surgical procedures performed at the hospital, and potential loss-to follow-up.
  • Serves as an educational resource on the MBSAQIP, CESQIP, and VQI programs for internal and external audiences by developing educational materials and delivering presentations.

4. Program Participation
  • Participates in weekly teleconferences with other quality monitoring analysts.
  • Attends national conferences pertaining to the programs, as requested.
  • Prepares and maintains data in accordance with program requirements in preparation for site accreditation and reaccreditation visits.

Minimum Education

  • Bachelor of Arts or Science required.

Minimum Related Experience

  • Clinical chart review and abstraction experience required.
  • Database data entry and/or management experience preferred.
  • Quality improvement or patient safety knowledge and experience preferred.
  • 5 years-experience working in a health care entity strongly preferred.

Minimum Computer Skills

  • Proficiency in Microsoft applications, including Access.
  • Knowledge of SAS and SPSS, preferred.

General Skills

  • Excellent written, communication, and presentation skills.
  • Ability to work independently to meet identified program data entry requirement timelines.

This position generally reports to: Research Manager, Department of Surgery, and the Program Directors for the MBSAQIP, CESQIP, and VQI programs.