Job Description: Quality Assurance and Clinical Support Specialist – Department of Anesthesiology

Data Monitoring & Interpretation

• Performs daily evaluations of anesthesia cases from the previous day, compiling quality metrics for short- and long-term reporting needs (daily, monthly, yearly).
• Detects emerging trends in clinical quality indicators and alerts the Quality Assurance Chair when concerns arise (e.g., increased use of general anesthesia, eye trauma, repeat intubations, drug administration mistakes).
• Produces routine reports on urgent intubations to identify patterns and assess clinician workload, especially during peak periods.
• Gathers and analyzes statistical data related to operating rooms and satellite procedural areas for comprehensive monthly summaries.
• Shares collected data with local site leaders to aid internal reporting and leadership briefings.
• Monitors ICU-related infection data (e.g., CLABSI), providing regular updates to the QA team on progress or emerging issues.

Quality & Incident Reporting

• Compiles monthly reports outlining key performance indicators, clinical case reviews, incident documentation, root cause analysis summaries, and mortality figures.
• Conducts follow-up reviews of corrective action implementations where care did not meet standards, submitting analyses to appropriate QA teams.
• Supports the preparation of the Department Chair’s annual presentation to the Board of Trustees with data and written content.
• Escalates unexpected clinical occurrences to the QA Chair for investigation and further evaluation.
• Tracks dental trauma incidents, arranges assessments, and prepares reimbursement documentation following review.
• Drafts semiannual performance evaluations for faculty, including detailed case audits for newly appointed staff. Topics include anesthetic documentation, reintubations, patient awareness, drug issues, and major adverse events.

Administrative Functions – Quality Assurance

• Responds to internal patient safety notifications (“keepsafes”), ensuring proper routing and documentation of follow-up actions.
• Assigns electronic QA reviews in coordination with QA faculty, ensuring completion within designated timelines.
• Organizes monthly QA meetings: develops agendas, documents minutes, and prepares slide presentations.
• Serves as the primary liaison among QA, patient relations, and various clinical departments to address concerns, patient feedback, and incident reports.
• Leads departmental quality improvement projects (e.g., monitoring for corneal injuries, glucose control in cardiac ORs, early NGT placement).
• Participates in internal review processes and root cause analyses for anesthesia-related events.
• Maintains confidentiality concerning patient data and provider performance at all times.

Administrative Functions – Clinical Operations Support

• Partners with pharmacy to address medication shortages, formulary changes, and drug safety issues; updates clinical staff on relevant modifications.
• Collaborates with the Clinical Director to coordinate specialized service requests, including off-site anesthesia coverage or patients with complex allergies.
• Provides guidance to staff on challenging clinical situations, such as patient injuries, disclosure obligations, and handling of medical record requests.
• Acts as a resource for faculty regarding clinical practice concerns, particularly in sensitive or high-stakes circumstances.
• Prepares and disseminates urgent updates to providers regarding clinical procedures, policy adjustments, and resource availability.
• Coordinates with departments such as surgery, neurology, and nursing on interdisciplinary issues, including initiatives like stroke documentation for certification.
• Attends departmental reviews, morbidity and mortality meetings, and safety-focused projects in the perioperative setting.
• Keeps all professional licenses and certifications current and completes required trainings.

Educational Initiatives

• Designs and circulates monthly continuing education (CE) materials during the academic year (September–June), utilizing literature reviews and expert collaboration.
• Identifies significant clinical cases for educational case conferences to support training goals.
• Monitors regional anesthesia procedure trends and reports data to leadership for fellowship program accreditation.
• Assists with residency education, including participation in QA meetings and root cause analyses.

Policy Management & Institutional Collaboration

• Oversees biennial updates and distribution of departmental clinical guidelines and protocols.
• Maintains and manages revisions of cross-campus policies, ensuring updates are reflected on internal platforms.
• Engages in departmental sustainability and environmental health initiatives.
• Conducts literature reviews to support benchmarking activities and quality improvement efforts.
• Collaborates with partner institutions on shared policy and quality concerns.
• Attends monthly quality and safety meetings with affiliated hospitals or partner sites.

Legal & Risk Oversight

• Coordinates with Risk Management to support case reviews requiring expert input and clinical clarification.
• Maintains a comprehensive archive of malpractice cases and legal reviews for internal reference and reporting.
• Arranges internal expert evaluations of clinical cases for legal or risk-related concerns.

Professional Skills & Expectations

• Demonstrates in-depth clinical acumen to support case review and decision-making.
• Promotes a patient- and family-centered care approach.
• Communicates effectively both verbally and in writing.
• Maintains a high standard of professionalism in all interdisciplinary interactions.
• Respects confidentiality and adheres to HIPAA regulations.
• Shows strong attention to detail and time-sensitive responsibilities.
• Proficient in Microsoft Office (Word, Excel, PowerPoint), EPIC, and research databases.
• Dependable, self-directed, and works well in collaborative environments.
• Keeps up-to-date with required certifications and professional development.
• Understands personal knowledge boundaries and proactively seeks guidance when needed.
• Upholds the mission of the department in patient care, education, and research.
• Represents the Department of Anesthesiology with integrity and professionalism at all times.
• Completes all required institutional assignments and compliance training's.