The PI CNM is a Registered Nurse who reports to the Director of Process and Performance Improvement or designee and who is responsible for the abstraction of clinical data from patients' medical records and submission of the data within the timeframes required by CMS, The Joint Commission and the hospital for analysis and public reporting.
The CNM must demonstrate attention to detail and prioritization, accuracy in abstracting and reporting clinical data and proficiency in the required data abstraction tools. The CNM must have the ability to accurately interpret data definitions and communicate both verbally and in writing the core measure variances to the Director of PI, the CCEO, the CCNO, Nurse Managers and other Department Heads as necessary. The CNM will be familiar with medical terminology, basic medical record design and requirements and be able to utilize basic computer skill, Microsoft Office and Microsoft Excel. The CNM will perform the duties of this position while maintaining the highest level of confidentiality.
1. Abstract medical records per CMS, TJC and hospital specifications. Case types include but are not limited to Sepsis, VTE, Stroke, Immunizations, Acute MI, Chest Pain, and Psychiatric Core Measures.
2. Identify charts to be abstracted per specifications.
3. Become thoroughly familiar with medical record documentation and documentation requirements.
4. Abstract data elements, verifying all medical data, and correct as needed.
5. Submit data elements in the electronic database for analysis and reporting.
6. Observe strict confidentiality of all information pertaining to quality assessment and improvement
activities and practice discretion and sound professional judgment at all times.
7. Remain current on measure specifications. Review QualityNet questions and answers on a regular basis. When specifications do not provide clear direction, submit clarifying questions to QualityNet.
8. Identify opportunities for improvement when measures are not met. Identify reason for failure, if possible. Prepare analysis report summarizing opportunities for improvement.
9. Provide consultative support to clinical/operational process improvement teams by identifying and recommending documentation improvements.
10. Participate in regulatory audits and surveys as necessary.
11. Provide reports monthly, quarterly or as requested to Director of PI, CCEO, CCNO or ARH system officials.
12. Perform monthly mortality reviews per hospital specifications.
13. Able to sit for long periods of time; able to walk throughout hospital on daily rounds; able to withstand the pressure of continual deadlines; able to concentrate and maintain accuracy in spite of frequent interruptions, able to work independently; and flexible to work with variable and/or changing requirements.
14. Self-starter with excellent time management skills and ability to function with minimal supervision.
15. Other duties as assigned.
1. Requires a professional level of knowledge of the clinical record or clinical competencies in clinical nursing.
2. Knowledge of Performance Improvement functions required; Performance Improvement experience preferred.
3. Management experience preferred.
4. Excellent communication skills, both verbal and written, required.