ACS Surgical Clinical Reviewer - NSQIP/MBSAQIP

Nemours Children's Health is seeking an ACS Surgical Clinical Reviewer (SCR) to join our team in Wilmington, Delaware.

The ACS Surgical Clinical Reviewer coordinates, collects, and completes American College of Surgeon's National Surgical Quality Improvement Program Pediatric (NSQIP/P) data on preoperative risk factors, preoperative laboratory values, intra-operative variables, 30-day postoperative mortality, and 30-day morbidity on patients undergoing surgical operations which meet program criteria. The Surgical Clinical Reviewer (SCR) is responsible for accurate data entry of over 130 data points into a secure database which is validated off sight and subjected to statistical analysis. The results of the data are available as an annual report, online reports, and data which can be downloaded for the purpose of report development.

The ACS Surgical Clinical Reviewer coordinates, collects, and completes American College of Surgeon's Metabolic and Bariatric Surgery Clinical Reviewer Surgical Quality Improvement Program (MBSAQIP Adolescent data on preoperative risk factors, preoperative laboratory values, intra-operative variables, 30-day postoperative mortality, and 30-day morbidity on patients undergoing surgical operations which meet program criteria. In addition, long term follow up, as outlined in the MBSAQIP program requirements, will be conducted. The MBSAQIP SCR is not permitted to be involved in supervising patient care and is not permitted to chart on any variables collected in the MBSAQIP Registry. 100% of metabolic and bariatric procedures performed at the center will be collected and entered into the MBSAQIP registry. The Surgical Clinical Reviewer (SCR) is responsible for accurate data entry of over 130 data points into a secure database which is validated off sight and subjected to statistical analysis. The results of the data are available as an annual report, online reports, and data which can be downloaded for the purpose of report development.

In this capacity, the SCR functions as an overall data analyst for the Nemours Enterprise. As this position is one of ongoing growth, knowledge in coordination of clinical data management is key.

• Follows standards of good clinical practice and HIPPA guidelines in collecting protected medical information.

• Demonstrates proficiency in maintaining accurate data entry on a timely basis following the strict guidelines of the NSQIP: P program criteria.

• Identifies precisely any or all occurrences throughout the surgical process as outlined by the standard definitions of the NSQIP: P program.

• Gathers data and builds quality assessment reports monthly, quarterly, and yearly then submits them to the NSQIP/Pediatric Advisory Committee.

• Maintains a collaborative relationship with the Surgeon Champions Nemours Enterprise and consults him/her in clinical issues where his/her expertise is required.

• Participates in all monthly NSQIP: P SCR phone calls or Webinars and attend the annual ACS NSQIP conference.

• Must have ability to maintain integrity of database as demonstrated by external audit.

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ESSENTIAL RESPONSIBILITIES: Surgical Clinical Reviewer (SCR)

Clinical Data Analysis, Reporting, and Management

• Conducts on-going data analysis and evaluation to identify performance gaps, trends, special cause variation, and potential causal factors. Utilizes appropriate visual graphical tools and data displays (including control charts) to provide data results, interpretation and meaningful conclusions. Where needed utilizes more advanced statistical tools and analysis.

• Assures that data is collected in a timely manner, based on internal or external timelines and deadlines.

• Collaborates with the Surgeon Champion and NSQIP Committee Members in the management of data presented and the identification of areas for improvement. This includes preparing progress reports, plans or policies as needed as well as develop long-range goals, objectives, and strategies for quality/safety improvement.

• Collaborates with the Infection Prevention Program regarding Surgical Site infection identification including integration of infection that meet NSQIP criteria

• Partner with the Program Manager of Children Surgical Verification to develop cross functional skills that support the basic responsibilities of the C.S.V. program when needed.

• Keeps Senior Director of Safety and Quality apprised of barriers to completion of objectives. This includes escalating any issues regarding data integrity, interpretability, completeness or accuracy.

Program Support

• Collaborates with Medical Staff, departmental leadership and key committees on the following:

  • Develop long-range goals, objectives, strategies and related implementation plans for quality/safety improvement. This includes facilitating the participation of departments, services or Medical Staff in organization-wide quality/safety activities. Additionally participates in the evaluation of the program effectiveness.

  • Assists in the identification of specific organizational needs and priorities related to quality improvement and patient safety utilizing a variety of sources including, but not limited to, measurement data, variance reports, patient/staff suggestions, team recommendations, comparative data, regulatory standards/reports, focus groups and knowledge-based information.

• Facilitates multidisciplinary teams or committees as assigned.

Job Requirements

• Bachelor's Degree required. Masters in Nursing or related field preferred.

• Minimum of 5 years of progressively more responsible experience in health care required.

• NSQIP SCR Certification (required within 1 year of hire).

• Certified Professional in Healthcare Quality preferred.

• Experience in program development.

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