Performance Excellence Specialist

10950 ACH Enterprise - Clinical Excellence

Full time

Yes

40

Day shift

Pay Range

$30.70 - $57.30

Major Responsibilities: Provides PI consultation, facilitation and data support to clinical CQI teams and non-clinical, operational teams. 1)Assists departments and divisions prepare annual performance improvement plans and indicators making recommendations as appropriate 2)Assist to develop indicators, identify best practices, analyze and trend data and maintain dashboards for monitoring of improvement initiatives 3)Assists teams in prioritizing and focusing their efforts on designing measurable key quality indicators using appropriate national or local benchmarks and creating appropriate targets or goals. Ensures that data source for indicators is easily obtainable and meaningful to the project 4)Provides guidance and support to team leaders and members to ensure an interdisciplinary, collaborative approach to CQI philosophy, methods and tools. Partners with team leaders to effectively pre-plan meetings, identify best methods to maximize efficiency and outcomes 5)Provides just-in-time training regarding CQI philosophy, tools and methods 6)Facilitates CQI teams; and causal analysis with teams and for processes as assigned 7)Provides support to teams including literature search, data collection, statistical data analysis and display 8)Assists in development and implementation of action and measurement plans to improve quality and reduce costs 9)Assists in writing and designing interpretive reports to highlight variations in clinical and non-clinical processes and outcomes for committees and senior leadership 10)Promotes patient safety by reporting issues through established channels and participating as requested in safety initiatives Assists the Director and Manager of Performance Excellence and ACH Senior Leadership in managing the infrastructure for support of process improvement teams and committees. 1)Proposes clinical, operational and administrative projects. 2)Assists Director and Manager in planning and providing quality monitoring reports for leadership, i.e., Quality Management Oversight Committee (QMOC), Medical Executive Committee, Bi-Campus PI Committee, Administration, Bi-Campus PI Teams, and physician peer review and others as needed 3)Assists the Director and Manager in responding to identified quality issues. 4)Assists in reporting Advocate outcome indicators and participating in system QMS initiatives, system QMS Audits, and mock regulatory surveys 5)Assists in facilitating in the Causal Analysis, LEAN initiatives and other CQI projects as assigned 6)Assists in the development and management of projects that employ a systematic method to identify, benchmark, and integrate best demonstrated practice 7)Assists in ongoing activities and monitoring to promote regulatory compliance and ongoing survey readiness 8)Participates in the education, implementation and monitoring of ISO 9001 standards and conducting QMS audits. Must complete QMS Auditor training within 12 months of hire Facilitates performance improvement through active participation in the Medical Staff Performance Improvement Committees, Functional Committees and Organizational Department/Divisional Committees, as assigned. 1)Facilitates clinical peer review process for assigned Medical Staff Peer Review Committees 2)Provides support to committee chairs which includes consultation on meeting agenda and report preparation, maintenance of minutes, correspondence and follow-up on all issues 3)Insures that the committees/teams are in compliance with regulatory agency requirements 4)Insures that the required interdisciplinary and hospital-wide performance improvement activities are reported and acted upon 5)Disseminates comparative data to identify opportunities to reduce variation, improve outcomes and integrate best demonstrated practices 6)Designs and implements clinical studies to identify variation in practice resulting in improvements in patient care 7)Assists in writing interpretive reports and visual displays (i.e., control charts, run charts, bar charts, etc) highlighting variations in clinical processes, outcomes and improvement opportunities 8)Assumes responsibility for the coordination PI activities for the following Committees and/or departments and services as assigned: Medical Staff Performance Improvement Committees, Nursing Department and Divisions, Functional Committees and Organizational Performance Improvement committees and teams as assigned Supports clinical information systems and preparation of clinical data reports for internal and external customers. 1)May be assigned as System Manager, for NDNQI, MIDAS Plus and other severity adjusted databases 2)Develops clinical and statistical information reports out of the appropriate information systems to satisfy internal and external customers. 3)Compiles statistical data and reports for use in decision making by Leadership Committees i.e., Administration, QMOC, Medical Executive Committee, Medical Staff and other performance improvement committees 4)Compiles statistical data and reports for use in decision making by Leadership Committees i.e., Administration, QMOC, Medical Executive Committee, Medical Staff and other performance improvement committees 5)Utilizes data from external databases for benchmarking as appropriate. 6)Utilizes websites, i.e. Qnet Exchange, Accrediting Organization Quality Check, Hospital Compare, etc., for monitoring and accessing publicly reported data. 7)Develops and maintains clinical process and outcome dashboards of key initiative data for internal reporting 8)Ensures reports are accurately prepared and submitted in a timely manner 9)Assures reliability of reports generated from Information Systems/CHIS through identification and resolution of problems related to patient care data 10)Develops and implements training programs for associates to the MIDAS Plus and other software programs as needed and provides assessment of competency Maintains professional competency and updates knowledge of current standards, requirements of regulatory agencies and innovations in technology to serve as a resource to specific CQI assignments 1)Participates in educational offerings and completes annual safety requirements 2)Keeps abreast of current trends in the field of CQI principles and regulatory requirements and shares that knowledge with the team and the organization 3)Maintains confidentiality and respect the right to privacy 4)Interacts sensitively to diverse teams and individuals and exhibits support toward individuals in all situations 5)Maintains current licensure and/or job specific certification(s) Education/Experience Required: • Bachelor of Science Degree in Health Information Management, Nursing, Medical Technology or other related health field or related work experience. • 3 years’ experience in Utilization Review/Case Management or Quality Improvement preferred. • Knowledge of Continuous Quality Improvement theory Knowledge, Skills & Abilities Required: • Working knowledge of computer operations. • Advanced communication skills • Advanced organizational skills • Ability to work with diverse teams and individuals • Working knowledge of databases • R.N. required; RHIA or RHIT preferred Physical Requirements and Working Conditions: •Ability to work under tight time constraints •Ability to travel locally to other Advocate sites •Ability to review electronic medical records and computer printouts on a regular basis •Ability to design visual tools and data displays •Ability to make presentations to groups and committee members •Ability to interact with committee members •Ability to extensively use a personal computer •Ability to work with and manage multiple projects This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.

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Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including:

Compensation

• Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training
• Premium pay such as shift, on call, and more based on a teammate's job
• Incentive pay for select positions
• Opportunity for annual increases based on performance

Benefits and more

• Paid Time Off programs
• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
• Flexible Spending Accounts for eligible health care and dependent care expenses
• Family benefits such as adoption assistance and paid parental leave
• Defined contribution retirement plans with employer match and other financial wellness programs
• Educational Assistance Program