Manager, Performance Improvement

Job Profile Summary

This role focuses on developing and implementing programs to establish, maintain, and improve patient quality care standards. In addition, this role focuses on performing the following Performance Improvement/Quality duties: Identifies and executes performance improvement and quality opportunities across the enterprise, enabling successful transformations and driving cost savings, process and product quality, and achievement of business goals. Responsibilities also include partnering with business leaders to provide expert insight on existing processes and procedures, applies process improvement methodologies to achieve PI/Quality objectives, and builds process improvement capabilities. A management role that supervises employees focusing on tactical, operational activities within a specified area, with the majority of time spent overseeing area of responsibility, planning, prioritizing and/or directing the responsibilities of employees. Goal achievement is typically accomplished through performance of direct and/or indirect reports. A role that manages experienced professionals who exercise latitude and independence in assignments. Responsibilities typically include: policy and strategy implementation for short-term results (1 year or less), problems faced are difficult to moderately complex, and influences others outside of own job area regarding policies, practices and procedures.

Job Overview

This position spearheads initiatives to create a culture of continuous process improvement and excellence. Manages the Performance Improvement Team and collaborates with leaders across the organization to identify and lead high-value initiatives, oversees and organizes strategic quality-related projects, and champions process improvement opportunities. Designs and executes targeted initiatives with the goal of improving operational workflow and achieving high levels of patient safety and quality as well as patient, physician, and staff satisfaction.

Job Description

Minimum Qualifications:

1. Bachelor's degree.

2. Relevant licenses and certifications.

3. Seven (7) years of progressive divisional/corporate administrative experience for multi-system division and acquisition integration.

Preferred Qualifications:

1. Master's degree in clinical area or Public Health, Health Administration, or another related field.

2. Ten (10) years of relevant experience in a healthcare setting.

3. Certified Professional in Healthcare Quality (CPHQ).

4. Six Sigma, Continuous Quality Improvement, Human Factors familiarity and/or training.

5. Corporate background with matrix organizational experience preferred, demonstrated business skills, experience with integrated delivery systems.

6. Prior experience of managing to CMS and Joint Commission Core standards and regulations.

Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned.

1. Provides direction necessary to ensure that clinical services are provided in accordance with standards established through state and federal regulations and Joint Commission accreditation standards, including the National Patient Safety Goals, and are evidence-based.

2. Provides coordination and oversight of proactive and reactive patient safety activities including root cause analyses, failure mode effects analyses and Sentinel Event Alerts in regards to the facilitation of process, planning, implementation and evaluation of effectiveness of process changes.

3. Assists with preparation of annual and semi-annual reports to BORM at the State and federal levels and seeks consultation from hospital committees and peers.

4. Participates in the monitoring, reporting, and improvement activities related to clinical guidelines, core measures, health care quality/safety initiatives, accreditation and regulatory requirements.

5. Acts as the clinical quality resource in Pay for Performance initiatives and oversees projects related to P4P initiatives.

6. Coordinates Core Measure data collection. Has primary responsibility for communication and compliance with Core Measure changes.

7. Fosters and maintains collaborative relationships with external agencies, purchasers, and stakeholders related to quality performance initiatives.

8. Collaborates with and serves as liaison to the ACNO, Clinical Operations, Quality and Patient Safety throughout the organization as necessary.

9. Performs staff performance evaluations establishing a development plan for each employee.

10. Provides administrative support for the Quality Assurance Committee (QAC) and Case Review Committee, as requested.

11. Provides orientation and continuing education system-wide including measurement techniques, criteria development, data retrieval, and data analysis.

12. Reviews quality management data related to clinical care and other sensitive areas with the Patient Care Assessment Coordinator and acts under coordinator's advisement and support.

13. Recommends to the Performance Improvement Committee projects to address potential and/or existing problems and areas identified by QAC, which could benefit from a performance improvement approach.

14. Provides patient safety leadership and reporting oversight of the reviews, analyses and patient safety report trends.

15. Advocates for patient safety and works collaboratively with Risk Management to promote a culture of safety, identify patient safety improvement opportunities, conduct assessments, champion reporting of patient safety events and near misses, and facilitate patient safety improvement.

16. Develops a methodology to display and distribute unit and hospital wide data to the clinical, non-clinical and medical staff and leadership.

17. Prepares and presents accurate, clear, precise data, graphs and reports as requested and as regularly scheduled.

18. Participates in committees, teams and work groups as assigned as well as other related duties incidental to the work described herein.

19. Presents quarterly reports on behalf of the Quality Assurance Committee, Readmissions Committee, and the Board Quality Risk Management Committee.

20. Reports and analyzes variances, serious incidents and/or severe breaches in the quality of care to the ACNO, Clinical Operations, Quality and Patient Safety.

Physical Requirements:

1. Frequent sitting, occasional standing & walking, and lifting of 5-10 lbs.

2. Requires manual dexterity using fine hand manipulation to operate computer keyboard.

3. Requires ability to see computer screen and reports.

4. Hours may be long and irregular.

Skills & Abilities:

1. Ability to manage project plans, action items, process flows, status updates for improvement activities across the medical center.

2. Strong analytic skills, knowledge of Microsoft office tools.

3. Ability to effectively educate Leaders and Department Staff on the performance data dashboards, findings and action plans that help drive improvements.

4. Ability to collaborate with leadership to act on opportunities for improvement within the organization ensuring that the clinical departments own the change.

5. Leadership skills in motivating clinical and operational teams, building consensus, and facilitating change in dynamic environments.

6. Ability to transform big picture concepts into concrete operational actions to improve quality of care, clinical outcomes and population health

7. Ability to communicate clearly and succinctly in writing and in speech.

8. Knowledge of healthcare operations across a broad range of clinical areas (e.g., quality improvement, population health).

9. Knowledge of the regulatory environment.

10. Ability to apply Process Redesign and or Change Management leadership focused on patient care and best practices.

11. Ability to lead quality and service improvement activities and achieve outcomes that respond to customer expectations.

12. Ability to collaborate and convene stakeholders across sectors and organizational levels.