Ministry Health Care Clinical Quality Improvement Specialist-Ministry Health Care (40 hours/week, Days) in Weston, Wisconsin

Title: Clinical Quality Improvement Specialist-Ministry Health Care (40 hours/week, Days) Location: WI-Weston-Saint Clare%27s - 3400 Ministry Parkway Other Locations: WI-Stevens Point-St Michael%27s - 900 Illinois Avenue Job Number: R-1412682

Clinical Quality Improvement Specialist Ministry Health Care

Ministry Health Care currently has an opening for a Clinical Quality Improvement Specialist. This position would float between St. Clare’s Hospital in Weston, WI and St. Michael’s Hospital in Stevens Point, WI.


The Clinical Quality Improvement Specialist helps drive improvements in patient care including but not limited to patient safety, patient satisfaction, quality, operational efficiencies, and employee work flow processes. The Clinical Quality Improvement Specialist is proficient in the use of tools that assist the team in the analysis of their work, and provides education and guidance in the use of these tools during the team’s activities. The Quality Improvement Specialist is an expert in the abstraction, submission, and reporting of quality indicator information to regulatory and quality organizations and in using this information to evaluate and improve the quality of services.


  1. Maintains current knowledge of TJC standards, WI state standards, CMS standards, as well as any other applicable regulatory agencies. Acts as a resource for other staff / units, including the Medical staff, in regards to regulatory bodies.

  2. Facilitate operational teams, including involvement of Medical Staff, in examining existing clinical and operational processes, and make recommendations for improvement.

  3. Support the Medical Staff’s peer review process through initial review of selected cases, based on approved triggers/indicators by the medical staff, and provide cases requiring further review to the medical staff.

4.. Assists the Medical Staff's provision of quality care and services through reviewing compliance with regulatory requirements, practice standards, and medical staff approved expectations

  1. Provide ongoing reports to Administration, Leadership, and the Medical Staff as requested..

6.. Is proficient in data extraction methods and processes, both concurrent and retrospective. Provide training, mentoring, and ongoing support to personnel performing data abstraction. Conduct audits of the data, ensuring the timely, accurate, and complete abstraction of data elements.

  1. Submits data and/or reports, on behalf of the organization, to regulatory agencies accurately and in a timely manner.

  2. Interacts and communicates accurately, consistently, and appropriately with both internal and external customers.

  3. Apply continuous quality improvement principles through careful methodological studies and innovative uses of decision support systems to facilitate implementation of these principles.

  4. Study ways to measure patients’ needs for services and assist in the design of measurement systems to support improvements in structures and processes utilized in the provision of services.

  5. Support monitoring changes implemented, measuring their effectiveness in direct relationship to identified process improvement activities.

  6. Facilitate multi-disciplinary team meetings to establish goals, analyze processes, and recommend changes for process improvement.

  7. Conduct follow-up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been recorded in the patient's medical record.

  8. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes.

  9. The Clinical Quality Specialist assigned to oversee the Risk Management activities for the organization will be expected to do the following activities in addition to those listed in #1 - #14:

a. coordinate and administer systems for risk identification, investigation and reduction

b. maintain risk management files in compliance with all applicable regulatory agencies

c. act as a resource for the organization in risk management issues

d. work closely with legal counsel and senior leadership on any lawsuits or court related proceedings

e. oversee and assist with investigations of all incidents, or events that could lead to financial loss of any type

f. provide education offering to associates, leadership, and community healthcare providers on risk management strategies

  1. The Clinical Quality Specialist assigned to oversee the Patient Advocacy responsibilities for the organization will be expected to do the following activities in additional to those listed in #1 - #14:

a. assesses individual patient and family's satisfaction with care, treatment and/or services

b. acts as an intermediary to hospital leadership on behalf of the consumer, representing their perceptions to associates and leadership

c. prevents complaints by counseling with supervisors and managers who see a problem developing; offering suggestions to resolve potential complaints; modifying practices that cause repeated complaints

d. documents complaints by listening to patient and patient family complaints; documenting details; determining what resolution is sought

e. investigates and manages complaints, grievances, or concerns from patients, their families, and other health care consumers regarding quality and/or delivery of care in conjunction with line management and associates

f. resolves complaints by listening to patients and their families; direction them to a physician or supervisor; helping them present facts to the hospital representative; developing acceptable resolutions; and following-up on outcomes. Assures documentation and communication of final outcomes to the patient and their families

g. provide educational offerings to associates, leadership, and community healthcare providers on patient advocacy and customer service Qualifications: Associate’s Degree in nursing required. Bachelor’s Degree in healthcare field, such as nursing, preferred.

Three years of recent clinical experience in a hospital setting is required. Experience within quality improvement, case management, discharge planning, or utilization review is preferred.

Current WI Nursing License Job: Quality Assurance/Improvement - Professional