Tennessee Hospital Association (THA) is a not-for-profit membership association, to serve as an advocate for hospitals, health systems, and other healthcare organizations and the patients they serve. The Association also provides education and information for its members and informs the public about hospitals and healthcare issues at the state and national levels.
The mission of the Tennessee Center for Patient Safety (TCPS) is to advance Tennessee hospitals' adoption of proven strategies that enhance the reliability, safety, and quality of care received by patients. The TCPS provides extensive education, resources, and direct support to hospitals to accomplish the mission of better outcomes for patients.
JOB SUMMARY:
The primary responsibility of the Clinical Quality Data Analyst is to support THA and the Tennessee Center for Patient Safety (TCPS) as an expert resource for data analysis and hospital/state performance with THA Hospital Investment Program (HIP) Quality measures, Centers for Medicaid and Medicare Services (CMS) measures, departmental operations, and THA member requests for review and analysis. The Clinical Quality Data Analyst will provide HIP program support through management and coordination of hospital data collection, analysis, feedback, and reporting. This position will report directly to the Director of Quality & Patient Safety Organization (PSO) in TCPS and will work closely with the TCPS Senior Vice President (SVP) and Information Services Department to provide reports and analysis to TCPS staff, member hospitals, and TennCare. The analyst will work with membership by actively engaging members through relevant data reports, benchmarking, and comparisons and interpreting complex clinical data using statistical methods and software tools. Further responsibilities of this position are providing direct support and education to hospitals in data collection, monitoring the completeness and accuracy of reported data, and ensuring compliance with measure definitions under the TennCare HIP Quality Component Program. They will also work with healthcare professionals and TCPS Clinical Quality Improvement Specialists to evaluate patient outcomes and process improvements.
ESSENTIAL FUNCTIONS OF THE JOB:
1. The ability to adapt to a changing work environment and meet challenges presented throughout the day.
2. Manage HIP Quality Component measures to meet program deliverables.
3. Organize, analyze, and aggregate hospital and state performance reports through both claims and facility data
4. Design, deploy, and monitor data quality metrics as part of the Hospital Investment Program-Quality Measure Component.
5. Develop and implement processes to monitor data quality and completeness of all routine tasks and special requests. Respond to data and HIP/CMS inquiries quickly to support hospital stakeholders, TennCare, and THA staff.
6. Work collaboratively with THA IT, Director of Quality & PSO, and TennCare development team in communicating needs around the HIP quality database and reporting tools. Collaborate with cross-functional teams to ensure data quality dashboards meet the needs of all stakeholders.
7. Consult and aid in the design and development of reports, visualizations, and analyses.
8. Maintain THA quality measure database for HIP.
9. Create and manage reports and dashboards for TCPS and TennCare specific to CMS and HIP measures. Data graphs include run charts, combo charts, pareto, scatter plots, histograms, and more.
10. Prepare data for presentation to committees, TCPS SVP, TennCare, and THA board of directors to ensure consistent messages from all levels of the organization.
11. Prepare data performance reports for hospitals, in collaboration with TennCare, and meet all applicable deadlines.
12. Serve as the primary point of contact for HIP quality performance reports to ensure timely submission, distribution, and quality incentive payments.
13. Distribute quarterly summary HIP performance reports to monitor progress for each participating hospital.
14. Participate in planning data collection tools for new HIP quality measures and communicate changes in collection and reporting to a broad stakeholder audience.
15. Serve as the liaison for data collection and reporting between TCPS, TennCare, and participating hospitals.
16. Drive automation initiatives to streamline data collection, analysis, and reporting processes, reducing manual efforts and increasing efficiency for participating hospitals.
17. Develop and implement quality control measures to ensure accuracy, completeness, and reliability of data throughout the HIP submission and analysis process. Identify and resolve data quality issues in a timely manner, working closely with internal and external teams.
18. Collaborate with THA IT to design submission fields into the reporting database.
19. Teach participating hospitals on new measures, data submission process, and interpreting performance reports. Education will include hosting virtual office hours and webinars.
20. Maintain the database of member hospital HIP quality component contacts in both the THA member and THA quality measure databases. This includes maintenance of system and data integrity; maintenance of hospital and system information; compilation and customization of reports; defining system needs; and adding, editing, and inactivating users.
21. Understand state and federal reporting requirements in the Center for Disease Control's National Healthcare Safety Network (NHSN), CMS, and The Joint Commission.
22. Work in collaboration with TCPS Clinical Quality Data Manager to administer and track NHSN reporting, including group rights, data compilation, creation of customized reports, and other quality initiatives.
23. Evaluate CMS and HIP Quality Measures and offer creative ideas to improve performance and workflows.
24. Support internal clinical and quality improvement staff by supplying data reports and trend information as needed.
25. Perform other tasks and duties as assigned by the Director of Quality & PSO and TCPS SVP.
26. Must be available in the office during regular office hours unless job responsibilities require otherwise, or hybrid work arrangement is in place.
27. Travel approximately 5 percent of the time, as necessary to fulfill job responsibilities; must be available for out-of-town travel, be able to drive an automobile, and maintain a valid driver's license.
DIMENSIONS:
Volume: 170+ hospitals—Working with members and non-members
Number of people supervised (direct reports): 0
GUIDANCE & DIRECTION: (Policies, precedents or procedures that guide this work)
1. TCPS is under the leadership of the TCPS SVP.
2. The THA Board of Directors and THA President and CEO guide the priorities and initiatives of TCPS.
3. The TCPS Quality Committee, Chief Nursing Officer (CNO) Calls, and Chief Medical Officer (CMO) Society may provide input and recommendations to TCPS.
4. The deliverables, HIP agreements, and grants outline the program and outcome expectations.
5. CMS Quality Measures, CDC NHSN, and U. S. Department of Health and Human Services (HHS).
6. Health Insurance Portability and Accountability Act (HIPAA).
7. THA Information Security Policies and Procedures.
Educational and Experience Requirements Needed to Perform the Duties of the Job:
1. Requires at least two years of experience working in healthcare, hospitals, public health, or healthcare performance improvement.
2. Bachelor's degree is preferred in a scientific or related healthcare field including, but not limited to, data analysis, health informatics, epidemiology, statistics, data science, public health, health information management, or business analytics.
OR
Consideration given to candidates with credentials as a Certified Professional in Healthcare Quality (CPHQ), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Project Management Professional (PMP), Clinical Informatics, data analytics, or similar certifications in healthcare or public health that also have an associate's degree.
3. Previous experience working with healthcare teams and familiarity with electronic medical records including, but not limited to, EPIC, Oracle (Cerner), and Meditech.
4. Previous experience working with healthcare claims data.
5. Working knowledge and understanding of clinical classification systems, such as the ICD and Healthcare Common Procedure Coding System (HCPS).
6. Experience working on a team and providing information via email and phone on process activities.
7. Experience in patient safety, clinical performance improvement, data abstraction, or outcomes measurement.
Skills Required to Perform the Duties of the Job:
1. Advanced computer skills–proficiency in Microsoft Word, Excel, PowerPoint, Outlook and Teams; spreadsheets; datasets; charts; and database software, such as SAS, Tableau, and/or SQL.
2. Working experience and knowledge with software like PowerBI, Tableau, and other data statistical and visualization tools.
3. Advanced knowledge of collecting, editing, and charting numerical data.
4. Strong analytical and problem-solving skills, with the ability to interpret complex datasets and extract meaningful insights.
5. Knowledge of hospital claims data (International Classification Diseases-10 (ICD-10), Diagnosis Related Groups (DRG), and Current Procedural Technology (CPT) codes—medical and coding terminology.
6. Understanding of data science.
7. Strong data management and organizational skills.
8. Ability to work on multiple projects concurrently and effectively handle changes in project requirements.
9. Ability to adhere to a schedule and meet deadlines.
10. Attention to completeness, accuracy, and detail.
11. Ability to handle requests and corrections by staff and members with courtesy and professionalism.
12. Ability to critically think and use independent judgment.
13. Strong interpersonal skills.
14. Work collaboratively within a team.
15. Creativity and vision to organize data in meaningful presentation formats to deliver key messages.
16. Effective written and oral communication skills.
17. Must maintain good working relationships with THA staff, member hospital staffs, and external partners.
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Important Information for CPHQ Recertification
The recertification process has been streamlined. Unlike previous years, you don’t need to list out your CE activities at the time of completing your application. Instead, you will be asked to attest to having met the requirements, further aligning with the honor-based system of recertification. In the event that your application is randomly selected for audit, you may be required to list your CE activities and submit supporting documentation.
While you may participate in NAHQ learning opportunities (Learning Labs, JHQ articles, etc.), you can only claim CE credit once for each activity. Therefore, if you’ve previously earned CE from a NAHQ learning opportunity, you can’t claim it again, nor will you see the repeat CE appear in your “My Learning� tab. This includes activities used in previous recertification cycles.
Remember, if you’re recertifying during the grace period (1/1/24-1/31/24), you already had to earn your CE hours by Dec 31, 2023.
You still have time! Register today for a multi-day virtual event that addresses the most urgent and important issues facing healthcare today that offers a full schedule of educational sessions organized around NAHQ’s twice-validated healthcare quality competency framework.
We are excited to announce the release of the book “UNSTOPPABLE: Inspiring Stories of Perseverance, Triumph and Joy from Trailblazing Women in Healthcare“.
Be inspired by nine leading healthcare trailblazers, including our own CEO Stephanie Mercado, who empower us all with their vision and passions.
You’ll notice we’ve simplified the application process to recertify. You will not have to list your CE activities at the time of applying*. Simply attest that you met the requirements to complete the application.
*In the event of an audit, CPHQs may need to list activities and upload documentation in their NAHQ account.
Quality Education Resources
Join this informative session, “Quality Education Resources� Thursday, June 22 from 11-11:30 a.m. CT. You will learn about the range of NAHQ quality education resources available to you and hear directly from universities about the benefits they realized from implementing NAHQ’s content within their courses.
Maintain a Pulse on the Latest Quality & Safety Benchmarking Data
Learn more about NAHQ’s enhanced Quality and Safety Benchmarking Program, which provides timely insights to help U.S. hospitals and health systems create data-driven business cases for their quality and safety resourcing.
Understand the Variability Among Your Quality Team Through Workforce Accelerator
Join us Tuesday, May 2, at 11 a.m. CT, to learn more about the different options available to engage with NAHQ’s enterprise-wide solution, Workforce Accelerator®. Options range in size and scope and are designed to meet the various budgetary and timing needs of health systems as they embark on their quality journeys. Register today!
Healthcare Quality and Safety Workforce Report: New Imperatives for Quality and Safety Mean New Imperatives for Workforce Development
The National Association for Healthcare Quality® (NAHQ) has conducted groundbreaking research on the advancement of the quality and safety agenda and has published the results in a new workforce report. NAHQ’s Healthcare Quality and Safety Report answers the question: “Is today’s healthcare workforce doing the work that will advance critical priorities of quality, safety, equity, value, and system sustainability?� The answer is no.
Updated Maintenance Dates: Sunday, February 5, 2023
Maintenance is planned for Sunday, February 5, from 11 p.m.-4 p.m. CT. During this time, you will not have access to the “My Learning” section of your NAHQ account. We apologize for any inconvenience this may cause and thank you for your patience.
NAHQ’s Organizational Membership Subscription will serve as a one-stop shop for healthcare quality and safety training and education. Attend the February 2, at 11 a.m. CT, info session to further understand the new offering that will continue NAHQ’s focus of “Quality in Action.�
NAHQ has published an updated version of the CPHQ exam content outline.
The new exam content will take effect on March 15, 2023. Candidates planning to take the exam before March 15, 2023, can access the current CPHQ exam content outline and related resources on our website.
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Healthcare Quality and Safety Workforce Report: New Imperatives for Quality and Safety Mean New Imperatives for Workforce Development
Member Briefing Workshop and Healthcare Quality Week Webinar
October 7, at 12 p.m. CT
NAHQ will host an exclusive member briefing workshop where NAHQ CEO Stephanie Mercado and NAHQ President-Elect Nidia Williams will review the workforce report in-depth and prepare you to discuss it with your team and leadership during Healthcare Quality Week.
October 17, at 12 p.m. CT
To kick off Healthcare Quality Week, (HQW) NAHQ will host a complimentary webinar with NAHQ leaders to discuss the report, its impact and how you can leverage the report to your advantage.
You still have time! Register today for a multi-day virtual event that addresses the most urgent and important issues facing healthcare today that offers a full schedule of educational sessions organized around NAHQ's twice-validated healthcare quality competency framework.