Quality Outcomes and Leapfrog Coord, Marshall Medical ...

This position will report to the Director of Quality through the Patient Safety & Performance Improvement Coordinator. The Quality Outcomes and Leapfrog Coordinator Essential Functions are comprised of 3 domains: Quality Outcomes Monitoring, Leapfrog Coordination and Performance Improvement Initiatives.OUALITY OUTCOMES MONITORINGMonitor and support facility performance on national quality programs including:CMS Hospital Star RatingsHospital Value-Based Purchasing (HVBP)Hospital-Acquired Conditions Reduction Program (HACRP)Hospital Readmissions Reduction Program (HRRP)Hospital CompareThe Joint CommissionEnsure alignment and integration of Leapfrog improvement strategies with other hospital quality initiativesIdentify overlapping metrics, data sources and improvement opportunities to maximize efficiency and impact across quality reporting programsIdentify gaps in care and collaborate with departments to address themEnsure accurate reporting to internal stakeholders and external regulatory agenciesLEAPFROG COORDINATIONManage and oversee the accurate and timely completion of the Leapfrog Hospital Survey for both facilitiesServe as an internal resource for directors/managers related to the required data collection and validation for Leapfrog metrics, and provide necessary education and consultation as neededCoordinate with clinical and operational departments to gather and validate the required data for Leapfrog metricsMonitor MMCs performance against Leapfrog standards and develop action plans for improvementMonitor changes in Leapfrog methodologies and scoring, communicate updates to department leadership and ensure alignment across facilitiesAttend conferences, webinars and education sessions to prepare for the survey submissionMaintain a database of submissions and scores by facility with a goal of incrementally improving scoresMaintain documentation required in the event of audit Expected to obtain Leapfrog Coach Certification within 6 months of hirePERFORMANCE IMPROVEMENT Performance improvement sets Specific, Measurable, Attainable, Realistic, and Time-Sensitive (SMART) goals and utilizes the Plan Do Check Adjust (PDCA) PI modelAct as Subject Matter Expert for Leapfrog submission for all service lines in performance improvement initiativesMeet with leaders on a regular basis to ensure they understand the data requested of them and make improvements/adjustments as needed to meet goals and targetsProvide periodic updates to leadership and hospital staff regarding current status and opportunities for improvementConduct data analysis, reporting, information sharing, and performance improvement including departmental follow-up when neededCreate customized reports and presentations as requiredUse methodologies such as Lean, Six Sigma, PDCA to improve patient care processesParticipate in setting aggressive, yet attainable benchmarking goals with measurable objectives and assist in the achievement of these goalsAssist with data tracking, graphs, presentations, and recognition programsRequirement: Bachelor’s degree in Nursing, Healthcare Administration, Public Health or other clinical field.ORAssociate’s degree in Nursing, Healthcare Administration, Public Health or other clinical field, and At least 5 years hospital or healthcare experience or related industry. Strong background in improving clinical outcomes Significant experience in coordinating and executing cross-functional team projectsPreferred Master’s degree or higher level in a clinical field 10+ years hospital or healthcare experience

Created: 2025-11-01