Job Summary
Responsible for supporting day to day quality management and performance improvement activities for assigned facilities and collaborates with leadership to promote continuous survey readiness.
Essential Functions
- Proficiently facilitates performance improvement efforts and coaches others in the development of performance improvement capabilities.
- Maintains competence in applicable licensure, certification, accreditation and other regulatory body requirements.
- Coordinates department and facility Performance Improvement Committee meetings, analyzes trends of performance metrics/business unit level dashboards, identifies opportunities for improvement, develops and maintains management action plans, measures success of these action plans and creates the records and follow-up metrics for each meeting and activity; reassesses approach to maximize success.
- Provides consultation to teammates and leadership in areas of quality, compliance, accreditation and safety.
- Facilitates assessments, develops, implements and evaluates corrective action plans based on past surveys and preparatory tracer activities.
- Develops strategies for improvement that include considerations for leading practice research and shares implementation results across the System.
- Utilizes facilitation skills, data analysis and statistical process control to effect improvement in quality and clinical outcome.
- Consults with and trains staff to implement monitoring and measurement tools, and data analysis techniques.
- Provides education and training on accreditation compliance and accreditation matters.
- Demonstrates knowledge of the principles of growth and development and possesses the ability to respond to age specific issues and data reflective of the patient's status.
Education, Experience and Certifications
Bachelor's Degree required; Master's Degree preferred. RN or other clinical licensure preferred; certification in health care quality, patient safety or related accreditation entity preferred, required within 2 years of employment. 4 to 6 years experience in healthcare or directly related field and 2 to 4 years leadership experience preferred. Knowledge of Lean Concepts preferred. Intermediate to advanced computer skills with demonstration of skill and competence in use of all Microsoft Office applications preferred. Previous experience or knowledge of TJC preferred.
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