HH Health System

Quality Outcomes and Leapfrog Coord, Marshall Medical Center North, Quality Management, Days

Job Locations US-AL-Guntersville
Hospital Marshall Medical Centers
Requisition ID
2025-65062
Position Type
Regular Full-Time
Department Number
MMCS-64830
Department Name
Quality Management

Overview

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 MONITORING

  • Monitor and support facility performance on national quality programs including:
    • CMS Hospital Star Ratings
    • Hospital Value-Based Purchasing (HVBP)
    • Hospital-Acquired Conditions Reduction Program (HACRP)
    • Hospital Readmissions Reduction Program (HRRP)
    • Hospital Compare
    • The Joint Commission
  • Ensure alignment and integration of Leapfrog improvement strategies with other hospital quality initiatives
  • Identify overlapping metrics, data sources and improvement opportunities to maximize efficiency and impact across quality reporting programs
  • Identify gaps in care and collaborate with departments to address them
  • Ensure accurate reporting to internal stakeholders and external regulatory agencies

  

LEAPFROG COORDINATION

  • Manage and oversee the accurate and timely completion of the Leapfrog Hospital Survey for both facilities
  • Serve 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 needed
  • Coordinate with clinical and operational departments to gather and validate the required data for Leapfrog metrics
  • Monitor MMCs performance against Leapfrog standards and develop action plans for improvement
  • Monitor changes in Leapfrog methodologies and scoring, communicate updates to department leadership and ensure alignment across facilities
  • Attend conferences, webinars and education sessions to prepare for the survey submission
  • Maintain a database of submissions and scores by facility with a goal of incrementally improving scores
  • Maintain documentation required in the event of audit
  • Expected to obtain Leapfrog Coach Certification within 6 months of hire

 

PERFORMANCE IMPROVEMENT

Performance improvement sets Specific, Measurable, Attainable, Realistic, and Time-Sensitive (SMART) goals and utilizes the Plan Do Check Adjust (PDCA) PI model

  • Act as Subject Matter Expert for Leapfrog submission for all service lines in performance improvement initiatives
  • Meet 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 targets
  • Provide periodic updates to leadership and hospital staff regarding current status and opportunities for improvement
  • Conduct data analysis, reporting, information sharing, and performance improvement including departmental follow-up when needed
  • Create customized reports and presentations as required
  • Use methodologies such as Lean, Six Sigma, PDCA to improve patient care processes
  • Participate in setting aggressive, yet attainable benchmarking goals with measurable objectives and assist in the achievement of these goals
  • Assist with data tracking, graphs, presentations, and recognition programs

Qualifications

Requirement:

Bachelor’s degree in Nursing, Healthcare Administration, Public Health or other clinical field.

OR

Associate’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 projects

 

Preferred

       Master’s degree or higher level in a clinical field

       10+ years hospital or healthcare experience

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