Maintains up-to-date knowledge of assigned abstraction standards, Carle key result areas, and department Quality Plan metrics. Collects unit data, conducts analysis, prepares reports, and assists with the compilation, display and interpretation of data to support clinical and operational decision-making. Reliably and accurately applies guidelines and definitions (e.g. core measure, GWTG, STS, Cardiac Registry and NSQIP) to the collection of quality data as evidenced through inter-rater review. Disseminates reports in a timely manner to individuals, committees, and departments as needed. Leads and conducts ISO audits and prepares reports for the evaluation of process reliability and effectiveness of improvement efforts. Conducts mock surveys and prepares reports for the evaluation of compliance with accreditation requirements and CMS conditions of participation. Partners with leadership in the design of department and diagnosis-specific quality improvement indicators, and the selection of clinical projects and priorities on an annual basis. Ensures the timely collection and entry of Quality Plan and Quality Dashboard data. Attends committee meetings as needed, to present data, identify opportunities for performance improvement, and develop corrective action plans. Assures Quality Plan documentation accurately reflects the unit's improvement activities and includes an evaluation of effectiveness. Establishes effective working relationships with those departments and disciplines whose support is necessary for the improvement of care delivery processes. Provides guidance, support and just-in-time training to clinical leaders and associates regarding continuous quality improvement along with regulatory/accreditation requirements and expectations. Provides support to designated teams or workgroups, partnering with the chairs to effectively pre-plan meetings and identify methods to maximize efficiency and outcomes. Develops educational materials or presentations as needed to enhance the knowledge, skill and competency of the staff to improve care delivery processes and outcomes. Identifies cases (per criteria) and prepares cases for review by medical staff peer reviewers and the Professional Practice Committee. Documents peer review findings, prepares physician letters, prepares annual peer review summary, and assures the maintenance of all peer review records. Participates in new physician and medical staff department chair orientation to the peer review process. Coordinates equipment, resources, and the delivery of interpretive services within the hospital. Provides education regarding interpretive services regulatory requirements, and patient care delivery expectations. Collects and analyzes data to meet Carle system, public reporting and regulatory requirements. Coordinates and oversees department and diagnosis-specific monitoring and improvement activities. Educates, consults and provides support to the interdisciplinary team and relevant performance improvement teams/collaboratives. Coordinates and manages the Medical Staff peer review process. Manages and coordinates interpretive services within the hospital. The QNS abstracts clinical quality data, leads ISO audits, conducts mock surveys, and communicates opportunities for improvement, patterns and trends to hospital, clinics, and medical staff leadership. This includes detailed information that needs to be collected, recorded accurately and submitted in a timely manner.