Under the supervision of the Clinical Data Center Manager, the Performance Improvement Specialist is responsible for implementation and monitoring of initiatives with a focus on improvement and compliance with the standards set by accreditation & regulatory agencies.  To manage, within a collaborative environment, the execution of assigned components of strategic initiatives. To partner with stakeholders in development of project plans to ensure implementation of key business initiatives.  To provide project management, facilitation, education, and data analysis support for the improvement of systems and processes.  To assist in the coordination and aggregation of information for use by management in its decision making in both general operations and in tactical and strategic planning.  This position functions as an experienced project manager coordinating large-scale singular projects or multiple smaller, less complex projects. Responsibilities may include coordination of the Professional Practice Evaluation (PPE) process and the Ongoing Professional Practice Evaluation (OPPE) process. Facilitating multidisciplinary performance improvement committees and supports other performance improvement activities. Confers with Risk Management, Nursing, Infection Control, Information Technology, and physicians to address quality and patient safety concerns. Communicates effectively with multidisciplinary staff.

PROJECT MANAGEMENT

- Facilitates quality, performance improvement and/or patient safety teams.

- Coordinates, and provides project management.

- Ensures that project goals and objectives are accomplished within prescribed time frames and that project sponsors or clinical champions are informed of project status.

- Acts as a change agent to promote the development and integration of systems thinking, customer focus and the use of improvement tools and methods in interdisciplinary teams.

- Facilitate change initiatives and coordinate implementation.

- Coordinates multi-media presentations to communicate PI and patient safety activities, team activities and achievements.

- Utilize good research and statistical design to guide decision-making.

- As assigned, facilitates Professional Practice Evaluation (PPE) process and the Ongoing Professional Practice Evaluation (OPPE) processes as described in their respective policies to include:

Works with Peer Review Chairpersons to develop the agenda and outlining the review responsibilities of each of the committee membersCompletes committee communications with providersNotice to Providers of cases being reviewed and case review outcomeInterventions to Address Identified ConcernsPrinciples of Review & EvaluationProfessional Practice Evaluation ReportsDevelops indicators based on specialty; identifies data source, and collects quality performance data and clinical information Analyzes and evaluates data and clinical information to identify quality issues and trendsPrepares reports and presentationsInitiates referrals for variances identified with protocols, documentation requirements, and quality guidelines that affect patient condition, length of stay, and /or effective utilization of resourcesInitiates referrals to Service Line Medical Directors for medical practice issues unresolved by nursing staff interventionInterfaces with Risk Management, Nursing Management, Infection Control and others, as needed, to share information and initiate referralsFacilitates PPE process to:Establish a positive, educational approach to performance issuesWith Fair, Constructive feedbackEffective dissemination of lessons learnedPromotion of Education SessionsPromotion of identification and resolution of System process issues

QUALITY IMPROVEMENT

Coordinates quality improvement program and processes in collaboration with appointed Service Line Medical Directors and Division Chief (physicians) and nursing leadership:

- Serves as internal consultant for hospital departments regarding clinical quality, performance improvement, data integrity, and patient safety.

- Identifies areas for improvements, designs improvement actions and coordinates implementation in conjunction with Accreditation and Performance Improvement Specialists and staff of other services.   

- Review quality data that are internally and externally reported, apprises leaders of performance and opportunities for improvement; communicates quality and safety goals; follows up on safety reports and implements improvements.

As assigned, functions as support to medical staff committees, interdisciplinary performance improvement teams, and hospital departments by performing the following activities:

- Works with physician chairpersons in developing the agenda, the charter, and outlining the responsibilities of each of the committee members;

- Collects quality performance data and clinical information;

- Analyzes and evaluates data and clinical information to identify quality issues and trends;

- Prepares reports and presentations;

- Initiates referrals for variances identified with protocols, patient condition, length of stay, and /or effective utilization of resources;

- Initiates referrals to Service Line Medical Directors for medical practice issues unresolved by nursing staff intervention;

- Interfaces with Risk Management, Nursing Management, Infection Control and others, as needed, to share information and initiate referrals

- Coordinates development and maintenance of an effective computerized system for tracking variances in care throughout the continuum.

DATA MANAGEMENT

- Design and prepare periodic PI reports including benchmarking

- Complete research studies related to PI

- Analyze data to sufficiently recognize trends and prepare special reports

- Communicate outcome data to stakeholders to positively effect program performance

- Develop and maintain auditing tools and databases to monitor performance

- Conducts a thorough review of the literature to ensure that action plans are based on best practices and appropriate standards

- Identifies all the elements that contributed to an event, develops action plans to prevent recurrence and ensures that those risk reduction strategies are completed

- Documents quality data into information systems (Midas; Excel; etc.) as outlined in policies and procedures

EDUCATION

Coaches and mentors staff and management in areas such as performance improvement and process management

PROFESSIONAL DEVELOPMENT

- Participates in professional organizations relating to quality improvement and patient safety.

- Actively promotes a positive image of The Christ Hospital with the public and professional community.

- Demonstrates a coaching approach in developing the skills and potential of all professional staff and promotes a sense of empowerment in performance of their duties.

- Supports compliance with all hospital policies/procedures.

Performs other duties as assigned

KNOWLEDGE AND SKILLS: 

EDUCATION: Bachelor’s Degree in a health related field, health care management, or business management required, Master’s Degree preferred.  Graduate Registered nurse from an accredited College of Nursing with BSN Degree preferred

YEARS OF EXPERIENCE:  A minimum of three (3) years of accreditation or health care management related experience or 3-5 years of acute care nursing is required. 

REQUIRED SKILLS AND KNOWLEDGE:   

Ability to effectively communicate with and effectively gain cooperation of attending physicians with regards to documentation needs and to effectively influence all members of the interdisciplinary care team during difficult case to achieve appropriate resolutions.

Ability to articulate complex quality measures, interpret Value Based Purchasing/CMS & TJC requirements, analyze data and make the analysis meaningful to the leadership team, staff and providers.

Ability to interpret medical data as documented.

Ability to manage multiple projects and handle change throughout the process.

Ability to work with a variety of disciplines and levels of staff across departments and the organization is required.

Current knowledge of rules, regulations, policies, and procedures related to third party payers, JC, CMS, and other regulatory agencies required.

Demonstrate emotional maturity and stability. 

Demonstrates personal commitment to quality safety and a highly reliable organization.

Good presentation, written and oral communication skills, with demonstrated analytical and problem-solving skills as well as time/project management skills.

Knowledge and application of a wide variety of advanced performance improvement tools and methods.

Knowledge and training in multiple computer systems required to perform position responsibility such as:  Microsoft office, Power point, Excel, Outlook required; EPIC and MIDAS experience preferred.

Knowledge and understanding of regulatory and accreditation agency standards preferred;

Knowledge of evidence-based practice and principals, care plan development and core measures.

Leadership, teaching, and QI/PI facilitation skills required

Leadership, teaching, and QI/PI facilitation skills required; ability to facilitate teams and/or committees to achieve required results.

Must be able to link the clinical effectiveness and clinical information areas.

Proficiency in multiple Microsoft office applications. 

Project management experience with complex and/or multiple projects that are related to the clinical or operational functional areas.

LICENSES REGISTRATIONS &/or CERTIFICATIONS :

Certification in Healthcare Quality (CPHQ) through NAHQ preferred, RN License in the State of Ohio

Other Credentials Required or Preferred:  Six Sigma, Lean