PI cooridnator

Performance Improvement Coordinator

POSITIONSUMMARY

The Performance Improvement Coordinator helps coordinate the development implementation and

evaluation of Mission Community Hospitals overall performance improvement program. This

includes but is not limited to the following activities: 1) supporting the organizations performance

improvement process 2) identifying performance trends as well as prioritizing and recommending

improvements; 3) investigating and tracking risk management incidents and 4) preparing selected PI

reports for committee meetings. The PI Coordinator also plays a supportive role in ensuring

compliance with accreditation and regulatory standards. The PI Coordinator reports to the

Performance Improvement Director.

MAJORRESPONSIBILITIES

SERVICE PERFORMANCE

customers warmly with a smile and immediately when they enter

department/unit/area.

how the customer may be helped with interest and concern.

attentively does not interrupt.

ownership and takes action to resolve customer needs and/or concerns.

attentive and responsive to the expectations of physicians and co-workers.

constructive criticism and modifies actions accordingly.

generous in acknowledging a job well done.

words and behaviors that express consideration concern and respect.

and holds staff accountable for meeting department customer service standards in the

performance of duties.

telephone skills effectively as outlined in the Star Service Program.

all private information about staff or patients confidential.

customers and their service requirements.

or exceeds customer service improvement targets as demonstrated by dashboards etc.VALUE ADDED INCREASES WORTH OF SERVICE TO MISSION COMMUNITY

HOSPITAL

in marketing activities of the Hospital including but not limited to committees/task

forces speaking engagements conducting tours Hospital sponsored health fairs.

to marketing materials such as brochures newsletters teaching materials.

in staff recognition activities in ways that reward behaviors reflecting positively on

Mission Community Hospital.

in interdepartmental / multi-department/house-wide process improvement

forums/taskforce/committees.

and implements solutions to challenges/problems.

with the development-related activities including fund raising programs and activities.

the marketplace and recommends new and creative business opportunities.

targeted existing services and product lines for cost/benefit and develops appropriate

strategies to improve growth where applicable.

in activities that contribute to professional growth and development.

SPECIFIC DUTIES AND RESPONSABILITIES

for coordinating facilitating and reporting hospital-wide PI activities/initiatives

including inpatient and outpatient Core Measure data abstraction.

for assisting with coordinating and facilitating hospital-wide accreditation and

regulatory agency survey preparedness and readiness.

performance improvement processes that lead to a positive and measurable patient care

and service impact.

a continuous performance and quality improvement effort and monitoring

and reporting system. Regularly reports the status of performance and quality

improvement efforts and impacts.

5.Reviews QualityNet website on a regular basis to keep abreast of new changes and

updates. Ensures requested information/data is submitted before deadlines.

needed PI data is collected and analyzed on a timely basis and makes recommendations

for future patient care and organization improvements based on the data.

out best performance and quality improvement practices making department leaders

aware of them and suggesting areas where they could be the Director of PI in coordinating the Quality Council. Develops and analyzes performance

improvement data for tile council designs and implements the necessary Quality Council

processes and systems.

the Director of PI in conducting a minimum of one failure mode and effects analysis

annually and reporting findings to appropriate senior management and PI committees.

theDirector of PI in conducting and/or facilitating a minimum of two Root Cause Analysis

(RCA)annually and reporting findings to appropriate senior management and PI committees.

the Director of PI in coordinating and facilitating peer review activities as needed.

policy and procedure standards comply with local state and federal law and regulatory

requirements.

changes in the administrative policies that conform to accreditation standards and

California/Federal regulations.

with developing and implementing policies and procedures that support the provision of

services.

and timely status reports to the Director of Pl and/or hospital committees as

required.

the Director of PI to ensure that mechanisms are in place for ongoing datacollection

analysis and reporting for important processes and outcomes throughout the organizationin order

to maintain and improve the quality ofpatient care and services.

and reports national/regional benchmarks or outcomes excellencetargets that assist in

identifying/supporting performance improvement opportunities.

a disciplined process improvement method (the FOCUS-PDCA methodology- identifies the

process barriers to outcomes and corrective action plans) and performance improvement tools.

Director of Pl in assuring thatprocess improvement teams and committees develop

strategies(based ontheir monitoringactivities) to improve patientcare outcomes by assuring that

hospital practices reflect the best knownscience; that best practices are identified and emulated;

that variations in clinical care processes are reduced; thatreversible causes ofpatient care

complications are identified and reduced or eliminated andthat DRG specific patientoutcomes are

both measured andcontinuously improved including but notlimited to FEMApatient safety

initiatives clinicalpathways restraint management code blue effectiveness/ outcomes staffing

effectiveness DHS corrective actions plans.

trends reports and displays baseline andconcurrent outcomes data demonstrating

effectiveness ofaction plans as compared to national/regional benchmarks or outcomes excellence

targets.

manages and keeps accuraterecords/files for largevolume of information that

includes datacollection; aggregation and display of information: statistics the dissemination of

information to appropriate committees and personnel;reports; corrective action plans status

resolution; follow-up and maintains a working knowledge of Joint Commission standards State of

California laws and statutes (e.g. Title XXII) CMS regulations policies and procedures

and community standards.

monitors and sustains compliance with accreditation and regulatory bodies.

MCHs continuous readiness for the Joint Commission DHS and CMS surveys

in collaboration with the Performance Improvement.

other duties as related or assigned.

COMPLIANCE

unusual occurrence forms within 24 hours of event if not completed by

department director/manager/supervisor.

promptly. any suspected or potential violations to laws regulations procedures

policies and practices and cooperates with investigations.

all transactions in compliance with all corporate and medical center policies

procedures standards and practices.

compliance with all applicablelaws regulations procedures policies

and practices required by the job based on the scope ofpractice of the position.

identification and reporting of occurrences of potential liability to the Hospital.

INFORMATION MANAGEMENT

information sources appropriately in department/unit operations.

department specific information systems applications efficiently and effectively.

and creates department specific information system application reports.

reality and validation assessments of data processed by the department.

as an effective resource to IS to ensure accurate entry/updating of department specific

systems applications.

with hospital policies accreditation agency standards and state and federal

confidentiality requirements related to management of information including HIPAA.

necessary training prior to initial equipment and software use.

software at an intermediate to advanced level.

Work Place Responsibility: Maintains a safe and healthy working environment.

Work ConditionWork is performed in an office setting and requires no hand-on patient care.

QUALIFICATIONS

California RN license required

of BSN degree preferred

two years acute hospital nursing experience required.

years performance improvement/outcomes management experience in acute care setting

preferred.

level of knowledge related to Joint Commission hospital accreditation standards Department

of Health and Human Services and the Centers for Medicare and Medicaid Services regulations.

Professional in Healthcare Quality (CPHQ) preferred.

English written/verbal communication skills.

skilled with experience using Microsoft Office software at an intermediate level.

9. Intermediate to advanced level Microsoft Excel database and statistical analysis skills required.