Healthcare Data Analyst is a position within the Quality Resources and Patient Safety Departments and Transformation Division of Billings Clinic. The Healthcare Quality Improvement Consultant serves as a subject matter expert regarding the continual analysis, development, validation, maintenance, and improvement in quality, patient safety, and infection prevention system applications. The Healthcare Quality Improvement Consultant operates as a subject matter expert in federal, state, and commercial payer reporting linked to public reported data, reimbursement, or certification. The subject matters include data management and reporting for patient experience, clinical quality, compliance, hospital acquired conditions, healthcare-associated infections, healthcare personnel vaccinations, patient safety indicators, patient safety events / sentinel events, surgical improvement indicators, mortality, readmissions, length of stay, and cultural assessment surveys. The Healthcare Quality Improvement Consultant provides consultative services focused on providing the highest quality and safest care to patients while decreasing risk to the organization. Scope of work may include acute care hospital, ambulatory clinics, branch clinic locations, ambulatory surgery center, and fully owned and affiliated regional facilities. The position reports to the Director, Quality Resources, Director, Patient Safety, and Infection Control, and assumes responsibility for one or more of the of the following data management and reporting functions:
Patient experience
Clinical quality measures
Hospital acquired conditions
NHSN reporting of healthcare-associated infections
NSHN reporting of healthcare personnel vaccinations
Safety event / sentinel event reporting
Hand hygiene reporting
Required public health reporting during declared emergencies (i.e., COVID-19, Monkeypox, measles, Ebola, novel influenza)
Patient safety indicators
Mortality
Readmissions
Surgical improvements
Quality improvement projects


Essential Job Functions


• Serves as a subject matter expert and source of analytical expertise in clinical quality, patient safety, and healthcare-associated infection data management and reporting of outcomes of care.
• Manipulates datasets, conducts statistical analysis, and performs quality checks on analytic deliverables and assures accuracy in data provided for decision making.
• Assists the director in the development of organization-wide policies and procedures, implementation of projects and materials.
• Participates in both short and long-term planning for the department.
• Identifies needs and sets goals for own growth and development in collaboration with department coordinator and director (Quality Resources, Patient Safety, Infection Control).
• Meets all mandatory organizational and departmental requirements.
• Maintains competency in all organizational, departmental, outside agency, and employee safety standards relevant to job performance.
• Supports and models behaviors consistent with Billings Clinic's mission, vision, values, code of business conduct, and service expectations.
• Performs all other duties as assigned or as needed to meet the needs of the department and organization.
• Validates data elements used for public reporting and assures alignment with data specifications for public reporting.


• Organizes, prioritizes, and performs data management project work to support the organizational strategic initiatives for quality improvement, patient safety, and infection control. Works in concert with leaders across the organization in explaining, accessing, extracting, synthesizing, validating, trending, and analyzing clinical information.
• Works directly with multidisciplinary teams to design report formats that effectively report data to support identified operational priorities and initiatives. Identifies the data required and internal/external means to gather that data; prepares quantitative and qualitative analysis within required deadlines.
• Serves as a resource for the data collection processes related to publicly reported data.
• Required skills include problem identification and resolution.
• Performs complex, in-depth analysis individually or as part of a team.
• Advanced in-depth organizational skills and analytical skills requiring creativity, logic, and the ability to conceptualize as well as break down concepts into detailed components.
• Analysis requires the use of information structures, information processes, and information technologies.
• Interpretation of complex regulatory algorithms and data schema.
• Responsible for establishing, validating, and maintaining the integrity of quality monitoring tools, data collection methods, case definitions, databases, or models to support analysis and improvement processes.
• Performs chart abstractions and/or develops and validates interfaces for data to comply with regulatory reporting standards and quality measures. Facilitates data management within required timelines for the organization's accreditation and regulatory processes, compliance, and site visits for federal, state, medical society, and commercial programs such as:
• o CMS (Centers for Medicare and Medicaid Services)
• o DNV (Det Norske Veritas) Accreditation
• o (HHS) Health and Human Services
• o NCQA (National Committee for Quality Assurance)
• o STS (Society of Thoracic Surgeons)
• o HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems)
• o Magnet Designation ANCC
• o MCCN Mayo Clinic Care Network
• o NSQIP (National Surgical Quality Improvement Program)
• o NHSN (National Healthcare Safety Network)
• o ACO (Accountable Care Organizations)
• o The Leapfrog Group
• o Patient Safety Culture Assessments and survey instruments
• o PSO (Patient Safety Organization)
• o Voluntary Patient Safety Event Reporting
• o Others as assigned
• Serves as a data and information resource for process improvement methodologies to fulfill the organization's strategic initiatives for quality measurement, management, and improvement.
• Acts as a liaison and expert resource for various quality reporting programs to identify problems and concerns regarding the overall performance of the system.
• Provides technical support and acts as a resource responding to procedural questions regarding quality reporting system functionality and technical interaction with other Billings Clinic system applications.
• Assists with dissemination of infection prevention, and healthcare personnel vaccination information.
• In consultation with Information Technology staff and vendors, may install software upgrades, troubleshoot software related anomalies and coordinate information sharing between information systems and databases, and end users (i.e., Cerner, RL Datix, WHO Net, TheraDoc, Phillips)
• Participates in systems testing and validation. Participates in the evaluation of information systems, vendor proposals, etc., that pertain to the quality resources department.
• Knowledge and in-depth understanding of program and report writing logic including healthcare information management and database extractions (i.e., Cerner fields for report writing and data extractions).
• Identifies the data required and the internal/external means to gather the data. Prepares quantitative and qualitative analyses within required deadlines for internal and external reporting needs.
• Gather, validate, analyze, compile, and present credible information to diverse groups and audiences.
• Serves as a subject matter expert for leadership, department management and appropriate staff regarding the interrelationships of data.
• Collaborates effectively with multidisciplinary team members to achieve analytical and programmatic goals.
• Takes a proactive approach to identifying problems and opportunities and recommending solutions that support the strategic direction of the department and organization utilizing Billings Clinic Operational Excellence methodology based on level of training.
• Researches, evaluates, and makes recommendations and/or initiates corrective action to resolve problems with the internal functionality of various quality, patient safety, and infection control reporting systems and/or integration of information between systems.
• Complex analysis of financial and utilization information leading to the identification and development of improvement recommendations.
• Acts as security administrator for various internal and external quality reporting programs/applications including access management, management of data submission, report analysis, dissemination of information.
• Supports quality activities and practices through utilizing the knowledge of clinical quality outcomes data, prevention and control science, process improvement principles, high reliability organizing, behavioral sciences, and quality standards for improving patient care and services.
• Effectively builds and maintains relationships with colleagues from key departments, including quality, infection prevention and patient safety, pharmacy, nursing, nursing quality, nursing leadership, surgery leadership, sterile processing, medical staff, risk management, materials management, volunteer services, human resources, organizational development, occupational/employee health, professional development, operational leaders, executive management, and other stakeholders through positive interaction, problem identification, and resolution.
• Reviews, analyzes, and applies existing regulations, standards, guidelines of applicable professional organizations and governmental agencies. Integrates regulatory requirements and current clinical quality data into organizational standards and practices.
• Reviews, applies pertinent information from current scientific literature and publications. Integrates relevant public health issues into practice.
• Assists in the development of methodologies to fulfill the organization's strategic initiatives for clinical quality outcomes improvement and required regulatory reporting.
• Educates and assists medical, nursing, and other clinical staff, management, and senior executive leadership, in identifying and capitalizing on opportunities for improvement and facilitates cross-functional team development, when appropriate.
• Standardizes processes to optimize learning from clinical outcomes data and clinical quality, patient safety, and infection control risk assessments.
• Maintains knowledge of regulatory, accreditation and reporting requirements at the state and federal levels.
• Monitors and analyzes process and outcome measure to evaluate effectiveness and sustainability of practices.
• Assists in the development of clinical quality, patient safety, and infection prevention education for in-service programs to departments.
• Assists with goal setting to improve performance in clinical quality outcome measures.
• Participates in performance improvement groups and activities as indicated.
• Performs other duties as assigned or needed to meet the needs of the department/organization.
• MANAGEMENT OF CRITICAL DATA, INFORMATION, AND REPORTING
• Manages clinical quality data and reporting for hospital acquired conditions, patient safety indicators, patient safety event reporting, healthcare-associated infections, clinical quality measures, clinical quality outcomes, patient experience, and surgical improvement programs.
• Responsible for collecting, extracting, and aggregating information from various systems, data repositories and performing analysis to provide meaningful information to stakeholders.
• Performs analysis of data and disseminates key findings to key stakeholders to improve outcomes of care quality and patient safety.
• Initiates investigations when unusual clinical quality outcomes are observed. Summarizes findings, reports findings to healthcare personnel, leadership for corrective action. Conducts investigations when indicated and assists in designing and promoting interventions targeted at improving clinical quality outcomes.
• Maintains accurate record of patient experience, hospital acquired conditions, healthcare-associated infection, serious safety and sentinel event, patient safety indicators, patient safety event reports, surgical improvement registries, and clinical quality measures data within software systems.
• In conjunction with Billings Clinic leadership, responsible for the development of various quality and patient safety dashboards/huddle boards as well as assumes primary responsibility to maintain, validate, and disseminate information within the required deadlines.
• Maintains accurate records of healthcare-associated infections following CDC's National Healthcare Safety Network (NHSN) specifications for surgical site infections, central line-associated infections, catheter-associated urinary tract infections, MRSA bacteremia and C. difficile following LabID Event, and ventilator-associated infections.
• Maintains accurate records of required communicable disease reporting as required by local and state healthcare departments.
• Assures accuracy of patient experience, hospital acquired conditions, healthcare-associated infections, patient safety indicators, serious safety/sentinel events, surgical improvement registries, and clinical quality measures data entry into program software and meets deadlines for reporting.
• Prepares reports appropriate to the recipients. Responsible for the distribution of defined monthly, quarterly, and annual reports and scorecards.
• Provides routine and custom reports to nursing, medical staff, oversight committees, operational leaders, executive leaders, and governing board.
• Works with team members, end users and others to refine requirements, new or re-design and deploys high-quality data queries / reports.
• Assists in preparing annual program reports (i.e., Annual Quality Resources Report, Annual Infection Prevention and Control report, and Annual Patient Safety Systems report.
• POLICIES, PROCEDURES, AND STANDARDS
• Assists with development and revisions of system-wide quality policies and procedures.
• Demonstrates understanding of regulatory and advisory guidelines through application.
• Reviews, analyzes, and implements regulations, standards, or guidelines of applicable governmental agencies, accreditation bodies, and professional organizations.
• Conducts activities to maintain continuous preparedness for periodic and annual accreditation surveys.
• Provides feedback to regulatory, advisory, and accrediting agencies regarding opportunities for improvement in standards and regulations.
• Resolves errors resulting in the rejection of records from data entry systems (i.e., NHSN).
• Conducts data quality checks and assures data accuracy and consistency.
• RISK MANAGEMENT
• Cooperates and collaborates with Risk Management for risk prevention.
• Provides support to Risk Management for resolution of issues related to the quality of patient care and services.
• HIGH RELIABILITY ORGANIZING
• Demonstrates understanding of high reliability organizing (HRO) principles through use of Universal Skills and behaviors that promote quality and safety for both patients and employees.
• Utilizes HRO Universal Skills in daily work.