Manager, Performance Improvement

  • St. Claire HealthCare
  • Morehead, KY 40351, USA
  • Jun 23, 2021
Full Time

Job Description

Under the general supervision of the Vice President for Quality and Resource Management, the Manager of Performance Improvement develops and implements the performance improvement plan; promotes continuous quality improvement culture throughout SCH; provides direction for committees, service lines teams and departments to achieve strategic goals, continuous improvement and program effectiveness; manages ongoing monitoring and evaluation of performance to achieve optimal patient care outcomes, customer service, resource management and patient safety; proactively researches, promotes and profiles best practice guidelines and benchmarks for operational, clinical and quality excellence; manages medical staff performance improvement committees, peer review and reporting; manages medical staff profiles, documentation and reports to demonstrate medical staff competency; manages performance improvement data systems to assure data accuracy, security and integrity; manages outcomes reporting to achieve SCH objectives and comply with regulatory mandates such as JCAHO core measures and public reporting; serves as system manager for MIDAS and other performance software; supervises SCH statistics and census database and reporting; provides education on performance improvement trends and topics; facilitates communication of quality improvement to staff; supervises requests for hospital data from third party payers and external customers; assures compliance with JCAHO and other regulatory requirements related to performance improvement; and supervises summer youth workers, vocational students, and other student/volunteers. Works independently and routinely has access to privileged information requiring discretion and independent judgment.   Duties/Responsibilities: •    Develops and implements the SCH Performance Improvement Plan.  •    Promotes continuous quality improvement (CQI) culture throughout SCH.  •    Provides direction for committees, service lines teams, departments and managers to achieve strategic goals, continuous improvement and program effectiveness (SWOT, goals/priorities, outcome measurements, membership). •    Coordinates the performance improvement plan, committees and reports to demonstrate and communicate program effectiveness to staff, Medical Staff, Leadership and Board of Directors. •    Manages ongoing monitoring and evaluation of performance to achieve optimal patient care outcomes, customer service, resource management and patient safety. Coordinates annual evaluation of the Performance Improvement Plan. •    Provides expertise in the development/implementation of patient safety plans, proactive risk assessments, root cause analysis and other risk reduction initiatives for SCH. •    Proactively researches, promotes and profiles best practice guidelines and benchmarks for operational, clinical and quality excellence.   •    Coordinates medical staff performance improvement committees, peer review and reporting as required by the Performance Improvement Plan, medical staff bylaws, and policies.  •    Manages medical staff profiles, documentation and reports to demonstrate medical staff competency. •    Manages outcomes reporting to achieve SCH objectives and comply with regulatory mandates such as JCAHO core measures and public reporting.   •    Coordinates CQI Teams and serves as team facilitator. Serves as resource to provide education on continuous quality improvement (CQI).  •    Demonstrates knowledge of relevant legislation, regulations, and standards of practice.  Implements applicable healthcare quality improvement standards, trends, and programs.  •    Communicates, or facilitates communication of, quality improvement initiatives to staff.   •    Serves as computer network supervisor for Quality Management department by budgeting/ordering necessary equipment, maintaining software and hardware for the department’s daily functions and appropriately coordinating with IT staff.   Serves as system manager for MIDAS software system by maintaining dictionaries, passwords, access, and securities of the system; troubleshooting system errors, and working with MIDAS and St. Claire’s Information Services department to maintain the quality improvement system house wide; build and run reports, smart track work lists, and rules within the system; train new users; perform daily checks of system function; and serve as system resource to maximize system utilization. •    Manages performance improvement data systems to assure data accuracy, security and integrity. •    Proactively evaluates and updates databases to comply with regulatory mandates such as JCAHO core measures and public reporting •    Supervises requests for hospital data from third party payers and external customers such as AHA survey, state licensure survey, OHIC insurance survey, Medicare survey, Anthem Blue Cross quality improvement project, Joint Commission survey application, and others.  •    Supervises SCH statistics and census database and reporting. •    Assures compliance with JCAHO and other regulatory requirements related to performance improvement. Active member of the JCAHO Task Force.  •    Supervises summer youth workers, vocational students, and other student/volunteers.  •    Works independently and routinely has access to privileged information requiring discretion and independent judgment.  •    Maintains collaborative and effective relationships with colleagues, staff, administration and medical staff. •    Participate in other departmental responsibilities as assigned. Education: RN or comparable degree in a health or hospital related field.  Bachelor’s degree or management experience required.       Experience:  Five (5) years of experience in healthcare, preferably three (3) years in Performance Improvement/JCAHO.   Licensure/Certification:  CPHQ preferred. Physical/Work Requirements:  The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit and use hands to finger, handle or feel. The employee is required to communicate effectively.  Specific vision abilities required by this job include close vision for reading and computer work. The employee must regularly lift and/or move up to 10 pounds, frequently lift and/or move up to 25 pounds, and occasionally lift and/or move more than 50 pounds.  The work environment described here is representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee works in an area with good lighting and climate control. The noise level in the work environment is usually moderate.

Employment Type

Full Time