Collect and submit reliable data to the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Responsible for coordinating and facilitating the performance improvement process by interfacing with all applicable hospital departments and medical staff to ensure implementation of the performance improvement plan. Work closely Surgeon Champion and surgical department members to identify opportunities for clinical quality improvement and other special projects as may be identified. Meet regularly with department heads and medical staff for strategic planning on clinical outcomes, regulatory standards, system goals and objectives, customer and physician satisfaction, performance improvement and cost effectiveness.

Remote core measures abstractor for VTE, Meaningful Use, HOP-Surg, HIP-SCIP, and ED through put

Successfully submitted Group Physician Reporting Option (GPRO) data on over 7000 patients to CMS within a 5 week time period in 2014. Coordinated abstractors, validating manual and auto-populated EMR data. Worked with IT on report development, submission process and ensured the quality of the data.Facilitated the organizational goal to reduce high utilization of resources by coordinating interdisciplinary team to reduce ED visits, readmissions and length of stay for sickle cell population. The team developed ED care plan order sets, outpatient clinic for multidisciplinary follow-up visits with psychology, social services, advanced nurse practitioner and medical director. Facilitated organizational goal to reduce risk-adjusted mortality index by coordinating interdisciplinary team to increase end-of-life discussion documentation in the electronic medical record. Conducted in-depth chart reviews of high resource utilizers in terminal cancer population, specifically identifying opportunities for improvement with end of life care, and documentation of advance directive patient-physician discussion.

Collected and analyzed data for BCBS-IL Quality Management Projects and HEDIS Studies. Performed site visits and medical record review for physician office, providing feedback and education regarding health plan and regulatory requirements. Coordinated health plan quality improvement projects, GPRO, and HEDIS studies.

Led projects for required clinical quality measure studies including the development, implementation and timely completion of chronic care quality study measures for Blue Cross Blue Shield, Silver Cross Managed Care Organization, and Advocate Physician Partners. Oversaw timely and accurate data collection of onsite medical record reviews at physician’s office. Captured appropriate clinical information needed to assure compliance. Monitored provider records to assure compliance with service delivery and quality standards.

Developed, implemented, coordinated and oversaw an effective licensed independent practitioner (LIP) staff peer review process that supported LIP reappointment, privileging, and clinical quality/safety in compliance with Joint Commission ongoing practitioner performance evaluation (OPPE), focused professional practice evaluation (FPPE) standards for LIPs.

Primary oversight of facility-wide patient safety program, assisting associates and physicians towards process improvements that supported the reduction of medical/health care errors and other factors that contribute to unintended adverse patient outcomes.

-Served as leader of system-wide clinical risk reduction initiatives, work teams and committees. -Provided consultations to multiple sites on the development of outcome measures, indicators, performance monitoring, data analyses and interpretation and use of decision support software.-Designed and provided education on clinical risk reduction initiatives and methodologies to sites.-Provided statistical analyses and graphical display to support clinical risk reduction initiatives.-Synthesized results of clinical risk data and recommended appropriate risk reduction strategies.