Stroke is the fifth leading cause of death in Michigan. In order to care for patients suffering from this critically important disease, Michigan Medicine is home to a Joint Commission Certified Comprehensive Stroke Center.
The Stroke Quality Coordinator works with the remarkable clinical faculty and staff to ensure that Michigan Medicine patients receive the highest quality stroke care available, and to continue to improve on the excellent care that is already present.
The Department of Neurology seeks a Stroke Quality Coordinator to assist with the development and management of the quality metric monitoring required to achieve and maintain certification. This includes, but is not limited to all data elements for certification by the Joint Commission such as:
- Compliance monitoring for The Joint Commission (TJC) Primary Stroke Center and CSC core measures and requirements,
- Centers for Medicare and Medicaid Services (CMS) quality reporting requirements metrics
- American Heart Association Get With the Guidelines Quality Measures (AHA-GWTG) and
- UMHS internal quality improvement data for initiatives such as Stroke Arrival Process metrics as well as patient satisfaction, clinical outcomes, safety, efficiency metrics, activity data and other data as requested.
The clinical analyst helps facilitate process improvement, coordinate improvement plans for the stroke program and guide diverse groups to reach consensus regarding appropriate interventions.
The clinical analyst will abstract, merge, manage, and prepare compliance and quality data in the form of useful information to aid analysis by CSC Leadership (Chairs, Directors, and Manager) who, with this information, can enhance the quality of clinical care for the stroke patients.
- Chart Abstraction and Audits: Develops and maintains tracking method for concurrent review of stroke patients to ensure compliance with all quality metrics. Performs accurate and timely data abstraction including but not limited to data for CMS, TJC, GWTG, QA initiatives, and the internal Stroke Log. Review all IV TNK and endovascular intervention cases to ensure protocols were followed; research details when problems arise, present case to Leadership. Maintains knowledge of measure specifications and data definitions necessary to complete this work. Participates in or leads inter-rater reliability sessions to ensure abstraction accuracy and success in external agency validation. Provides training to other team members and serves as a resource for data abstraction requirements, ensuring reliability and validity of data.
- Data Management: Works with data from many different clinical and administrative sources (internal and external to the UM-CSC) and has expertise to abstract, merge, manage, and prepare the data in the form of useful information to aid in analysis. Creation and maintenance of program specific patient satisfaction data as requirement by TJC, assessing and communicating trends for CSC leadership to determine correct interventions to reduce readmission rates and manage patient needs in correct level of care setting (e.g. outpatient clinic).
- MiChart/HITS/Vendor Liaison: Collaborates with MiChart and HITS teams to optimize documentation efforts for clinicians, building of reports used for monitoring quality measurements and process improvement activities. Assists the team in creating crosswalks/uploads to external vendors utilized by the institution for reporting to external regulatory agencies. Troubleshoots any functionality issues with vendor products.
- Data Review and Quality Improvement Support: Thoroughly reviews clinical metric performance, assess for trends and underlying causes for deficiencies for escalation and review by the CSC Program Manager. Participates in a CSC quality, stroke arrival, and peer review meetings to support the data analytic portion of the process. Attends morbidity and mortality conferences for neurology, neurosurgery, neurointerventional radiology, and vascular surgery to ensure compliance with the monitoring and review of complication and mortality data as required for CSC programs. Monitor changes in laws, regulations and policies (specifically in the federal registrar that impact performance measurement and reimbursement) and assure compliance with reporting procedures and work flows.
- Reporting: Expertly produces all internal and external performance reports which include but are not limited to Stroke Core Measures, Stroke GWTG, Stroke Arrival, Peer Review, Comprehensive Stroke Measures, and CSC program specific elements that assist the CSC leadership in managing quality patient care to stroke patients as well as the program overall. Creation and maintenance of a real time dashboard for clinicians to utilize in increasing performance of our quality metrics for delivering interventions (IV TNK and endovascular therapies) to stroke patients. Provides reports for ad hoc meetings to address specific areas of deficiency. Maintains all databases for the CSC program and responds to requests by providers for data for research purposes. Provides training for report creation and serves as a resource for other team members, ensuring reports meet the standards of timely, discernible, reliable, meaningful, and actionable.
- On-Site Review: In collaboration with the CSC Program Manager, provide guidance and assistance i
