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Cape Cod Healthcare

Hyannis, MA
Job Code:
  • Management
  • Healthcare
  • Education
Cape Cod Healthcare
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Job Details

Responsible for data measure analysis, service line activities and special projects to support safe patient care and compliance with Pay for Performance, Regulatory, Patient Safety, Process and Systems Improvement, Public and Internal Reporting, and Peer Review requirements.

Pay for Performance:

  • Responsible for the data abstraction of all applicable data measures with strict adherence to the specifications manuals provided by the regulatory body.
  • Demonstrates applicability of methodology and reliability of definitions of the Core Measure data elements through careful monitoring of data entry into MIDAS.
  • Maintain current working knowledge of the changes in data definitions and variables for reporting said data measures as assigned responsibility.
  • Is responsible data accuracy, meeting submission timelines for all required entities as assigned by Director.
  • Responsible for searching external databases and web sites to keep current on all data submission requirements and specifications and using data abstraction tools to produce meaningful analyses and correlation of data.


  • Elicits support necessary to obtain valid, reliable data for reporting to regulatory agencies by remaining current with the regulations/standards and/or requirements as defined by these agencies (eg. CMS, BoRM, Joint Commission, DPH).
  • Maintain current knowledge of all Regulatory changes/Updates and communicate changes to Hospital committees, taskforces and teams as appropriate.
  • Coordinate activities with Director for successful accrediting, licensing, and certification survey activities as assigned (eg, JCAHO, Dept of Health, Centers for Medicare/Medicaid Services, BoRM as assigned by service line in coordinating completion of the Semi-Annual Quality Analysis Reports for submission to the BoRM in collaboration with Director of Quality.

Patient Safety:

  • Participate in RCAs and FMEAs as assigned and facilitate process change based on the findings of these activities.
  • Provide support to staff for monitoring and summarizing the effectiveness of the process change.
  • Provides feedback to management on process improvement initiatives, dashboard data, and indicator screening trends as assigned by service line or committee.

Process and Systems Improvement:

  • Collects, aggregates, analyzes, and reviews data for improvement opportunities.
  • Coordinates efforts in the development and implementation of action plans to resolve identified clinical/process issues utilizing the PDCA rapid cycle methodology.
  • Collaborates with clinical educators, coders and other staff to serve as a resource regarding core measures requirements and other quality initiatives.
  • Utilization of identified national benchmarks and standards of care in the development of such actions plans.
  • Supports a hospital-wide culture for continuous quality improvement.
  • Facilitates and collaborates in the designing of new processes that develop/monitor quality indicators.
  • Establishing innovative processes to improve quality.
  • Preparing reports and improvement plans.
  • Consulting on quality monitors, including data collection, sample size, and analytical tools.
  • Supporting our Performance Improvement/Patient Safety /Quality initiatives and taskforces.
  • Maintains proficiency in the use of MIDAS+, DataVision and, all other databases as assigned.

Public Reporting and Internal Reporting:

  • Assesses clinical and non-clinical outcomes using the measurement systems established, including data collection analysis and correlation and dissemination of information to internal customers.
  • Responsible for searching external databases and using data abstraction tools to produce meaningful analyses and correlation of data in simple, understandable graphic format for internal customers.

Peer Review:

  • Under the guidance of the CMO, assist the Medical Staff and Department Chiefs with peer review activities.
  • Organize findings, actions and recommendations and oversee the maintenance of the MIDAS peer review database.
  • Provide trend analysis of physician specific quality data for re-appointment purposes and performance improvement initiatives.
  • Assists the Executive Director, Quality, the Medical Director, the Chief of Staff and the Chief Quality Officer to ensure the compliance of the Medical Staff with JCAHO Standards, Department of Public Health Conditions of Participation, OSHA regulations and the Board of Registration in Medicine PCA semi-annual reporting as assigned.

  • Current RN License Baccalaureate Degree or Masters Degree preferred CPHQ preferred.
  • Excellent Presentation and facilitation skills Demonstrated competence in quality data analysis and presentation.
  • Minimum of 5 years of experience in healthcare with progressive experience in quality improvement, preferred.
  • Minimum of 5 years of experience in Quality Database and/or system management preferred.

Schedule Details: Full-time 40 Hours per week 8a-4p Monday-Friday
Organization: Cape Cod Hospital
Primary Location: Hyannis
Department: CCH-Quality / Patient Safety
Employee Classification: Regular-Regular
Shift: Day
Weekend Shifts: None
Holiday Shifts: None
Posting Start Date: Jan 22, 2018
Posting End Date: Ongoing
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