JOB DESCRIPTION FOR JOB TITLE:
|Program Director, Performance Excellence |
|Job Code: 851004 |FLSA Status: Exempt |Mgt. Approval: Cheryl Bowman |Date: 6-19 |
|Department : 5302 Transplant Administration |HR Approval:Troy Schuhmacher |Date: 6-19 |
|JOB SUMMARY |
|Under the direction of the Director of the Organ Donation and Transplant Service Line (Service Line), the Program Director, Performance Excellence is responsible for |
|developing and implementing a comprehensive performance excellence program focused on aligning resources, processes, people, actions and results; identifying strengths |
|and opportunities for improvement; and building a sustainable management framework that improves communication, productivity and effectiveness to achieve strategic |
|goals. The success of this program will result in delivering ever-improving value to patients and families or other key stakeholders; improving the service line’s |
|overall effectiveness and capability; and fostering a culture that embraces openness to change, improvement, learning, and innovation. The incumbent will serve as an |
|expert resource for: healthcare quality improvement and systems redesign, performance measurement, patient safety, and project management. The incumbent will assist |
|with on-going regulatory preparedness and audits, policy development, and operational and capital budgets to develop short and long term strategic plans as it relates |
|to advancing the performance excellence program for the service line. |
| |
|Internal and external customer relationships comprise a substantial percentage of this position. The essence of the position is in developing and improving these |
|relationships to achieve strategic performance excellence goals. The incumbent will work collaboratively with a range of professionals including high-level |
|administrators, directors, managers, physicians, nurses, and frontline staff working in departments involved in the donation and transplantation system. The incumbent |
|will also serve as the liaison between the UW Health Quality, Safety and Innovation (QSI) department and the service line in order to link the service line to |
|enterprise-wide quality improvement initiatives (i.e. hand hygiene, etc.) and to integrate and advance the UW Health Improvement Network (UWHIN) within improvement |
|initiatives, thereby increasing the capacity for improvement. The incumbent will engage in efforts and to stay current on new initiatives, training, and tools that may |
|help to advance the performance excellence program of the service line. |
| |
|Service Line activities, quality and success must be continually measured and analyzed against strategic performance goals, multi-year trends and industry standards. |
|For the service line to be making appropriate strategic decisions, reporting its results to essential stakeholders, and maintaining certification/accreditation, the |
|incumbent ensures vital data is objectively and judiciously collected and transformed into useful clear strategic information that drives meaningful action towards |
|performance excellence. |
| |
|The incumbent is responsible for the leadership and guidance of team members that support the performance of the service line. This includes identifying and aligning |
|resources from departments such as Enterprise Analytics, Quality, Safety and Innovation, Center for Clinical Knowledge Management, etc. as well as service line |
|resources such as data analysts, quality improvement champions and content experts. Alignment and collaboration should be inclusive of resources in the Department of |
|Surgery, Department of Medicine, School of Medicine and Public Health and UW Hospital and Clinics. |
| |
|The complexity of issues encountered range from extremely complex and sometimes unsolvable issues. The incumbent must be able to balance both attention to detail and a |
|broad perspective Most problems are solved using previous experience, established internal and external relationships and knowledge as the primary resources. A high |
|degree of organizational and problem solving skill is necessary in this position. |
|MAJOR RESPONSIBILITIES |
|Performance Excellence Program Development and Management |
| |
|Provide Leadership to Create and Implement a Service Line Performance Excellence Plan: how we align strategic goals, mission, vision, values to embrace improvement and |
|innovation to achieve results. |
|Lead the development of a system that makes current performance on quality improvement, safety and service transparent to service line leadership and staff. |
|Present quality updates at the quarterly service line all staff meetings |
|Serve as a peer colleague to the OTD and Transplant Operations Directors to coach, mentor and develop as a high performing team able to execute quality improvement |
|initiatives. |
|Lead the preparation and facilitation of the quarterly quality leadership meetings for OTD and transplant |
|Prepare annual report to PIRMS committee and/or Authority Board on transplant, OTD and HLA quality initiatives |
|Facilitate annual review of Quality Assessment and Performance Improvement (QAPI) plan for UW Transplant and ensure ongoing regulatory readiness related to QAPI, as |
|required by CMS and United Network for Organ Sharing |
|Oversee patient safety and adverse event process to ensure thorough analysis of safety events impacting transplant patients, living donors and donor families |
|Involve patient and family members in quality improvement initiatives and ensure the patient voice is represented throughout the performance excellence program. |
| |
|Create and Implement a Management System for Continuous Quality Improvement and Innovation: how we manage and continually improve work processes on a daily basis to |
|deliver customer value affecting success and sustainability |
|Lead the development of a system to receive, prioritize, approve and monitor quality improvement initiatives for the service line, inclusive of program leaders’ |
|authority to manage pace and prioritization of change. |
|Facilitates and/or supports improvement work at all levels of the service line and acts as an agent of change for continuous improvement efforts. |
|Fosters a culture where there is “pull” for learning and a commitment to spread improvements from operational leaders. |
|Incorporate quality improvement expectations into job descriptions, core competencies, performance evaluations, affiliation agreements and status meetings for all |
|staff. |
| |
|Data Measurement and Analysis: how data is selected, gathered, managed, including use of information technology, to inform and improve performance. |
|Facilitates the development of systems to translate data into useful information for organization staff, leaders, and various stakeholders. |
|Continuously improve the service line dashboard and leading indicators built around the Institute of Medicine’s 6 aims for improvement: |
|Safe: avoiding injuries to patients from the care that is intended to help them |
|Effective: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit. |
|Patient-Centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patients values guide all |
|clinical decisions; incorporate voice of customer data into quality improvement initiatives. |
|Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care. |
|Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy. |
|Equitable: providing care that does not vary in quality because of personnel. |
|Foster collaboration among the abdominal, cardiopulmonary and OTD data offices |
|Collaborate with transplant data office to implement quality analytic tools and predictive modeling for evidence based decision making. |
|Monitors the performance outcome metrics of regulatory and external reporting agencies related to the service line. Uses this data to inform decision-making and |
|planning for initiatives aimed achieving high levels of performance. |
|Supports the development and improvement of policies and procedures for appropriate collection, analysis and reporting of data for external regulatory reporting |
|purposes throughout the service line |
| |
|Learning and Development of Service Line Staff and Faculty: how we assess and increase staff and faculty’s capability and capacity for generating high performance work.|
|Partners quality improvement teams with operations at the point of patient care or workflow for coaching and mentoring. |
|Develop and conduct quarterly training sessions for service line managers, directors and physician leaders on advanced QI tools. |
|Develop and conduct workshops with project teams to advance QI initiatives and mentor quality champions. |
|Encourage and inspire service line staff to participate in the UWHIN educational courses, with a focus on action to pull the need for education rather than push. |
| |
|General Management Activities |
|Provides input and expertise to Director in developing long-range plans to increase the number of referrals from referring hospitals and converting all eligible donors |
|to actual donors, which in turn, would increase the number of organ donors. |
|Serves on the service line leadership team and gives input on the operational management and strategic planning activities of the service line. |
|Responsible for budget development with respect to value analysis across the service line. Ensure targeted savings are met in identified cost centers as it relates to |
|labor and supply utilization. Collaborate with other departments related to transplant for budgeting purposes, including pharmacy and surgical services. |
| |
|Human Resource Management and Staff Development Activities |
|Work with Human Resources for matters concerning employees directly supervised |
|Supervise and manage the workload of the quality analyst, data coordinators and regulatory specialist. Administer human resources policies for staff including the |
|assignment of responsibilities. |
|Oversee the recruitment, hiring, assignment of work, discipline, and scheduling of staff. |
|Interview and select candidates who have appropriate customer service skills and professional characteristics to match service line needs. |
|Communicate on an ongoing basis with employees regarding specific performance expectations. Plan and conduct formal performance reviews that are timely, ongoing and |
|objective and submit necessary documentation. |
|Responsible for the promotion and termination of employees based on standards of practice, standards of care and hospital policies and procedures. |
|Ensure direct reports have accurate position descriptions. |
|Promote growth of staff in areas such as group process, decision-making and customer service skills by identifying strengths and weaknesses, goal setting, formal and |
|informal learning and coaching. |
|Direct and develop leadership and management skills by mentoring and role modeling. |
|Delegate activities/work projects to staff and supervise their accomplishments. |
|Oversee and participate in the training and orientation of all new staff. |
|Foster a work environment that supports collaboration, participation, and appreciation of all team members. |
|Professional Development |
|Seeks opportunities to learn best practices and expand knowledge base related to advancing strategic performance excellence goals and programmatic initiatives. |
|Collaborate with the UW Health QSI Department and participate in educational and professional development opportunities as appropriate. |
|Attends required continuing education courses related to area of specialization to remain current in the field. |
|Maintains professional growth and development and keeps abreast of latest trends in areas of expertise. Brings and shares new information with Senior Administration and|
|the institution in general to increase the institutional knowledge base. |
| |
|ALL DUTIES AND REQUIREMENTS MUST BE PERFORMED CONSISTENT WITH THE UW HEALTH PERFORMANCE STANDARDS. |
|JOB REQUIREMENTS |
|Education |Minimum |Bachelor’s degree in business or healthcare field |
| |Preferred |Master’s degree in business or healthcare field |
|Work Experience |Minimum |Five (5) years of experience in quality improvement |
| |Preferred |Five or more (5+) years in healthcare quality improvement in an organ procurement organization, transplant center or |
| | |large academic unit |
|Licenses & Certifications |Minimum | |
| |Preferred | |
|Required Skills, Knowledge, and Abilities |Broad knowledge of organ procurement and transplantation, as well as healthcare administration. |
| |Demonstrated competency in data management and analysis. |
| |Ability to produce a high quality work, draw projects to completion in timely manner with demonstrated outcomes. |
| |Strong computer skills |
| |General knowledge of regulations (CMS, UNOS, AOPO, Joint Commission, etc.) and able to translate regulation into |
| |effective strategies to assure compliance. |
| |Knowledge of performance improvement tools and utilizes them effectively to lead/facilitate teams. |
| |Ability to respond and adapt to an ever-changing, complex environment. |
| |Strong organizational and project management skills. |
| |Strong interpersonal skills to include the ability to facilitate, mentor, negotiate, resolve conflicts, and build |
| |teams. |
| |Ability to function independently and have creativity and vision as well as the ability to manage multiple projects |
| |simultaneously. |
| |Effective leadership abilities: |
| |Ability to implement change in a positive, sensitive, and forward-thinking manner |
| |Develops goals and establish priorities |
| |Inspires confidence |
| |Achievement of high standards |
| |Self-starter with a willingness to try new ideas |
| |Ability to work collaboratively with others and develop consensus |
| |Ability to effect collaborative alliances and promote teamwork |
| |Effective communication skills both written and verbal presentation with a communication style that is open and |
| |fosters trust, credibility and understanding. Incumbent is a good listener and will follow through. |
| |Effective analytic ability in order to develop and analyze options, recommend solutions and solve complex problems |
|PHYSICAL REQUIREMENTS |
|Indicate the appropriate physical requirements of this job in the course of a shift. Note: reasonable accommodations may be made available for individuals with |
|disabilities to perform the essential functions of this position. |
|Physical Demand Level |Occasional |Frequent |Constant |
| |Up to 33% of the time |34%-66% of the time |67%-100% of the time |
|x |Sedentary: Ability to lift up to 10 pounds maximum and occasionally |Up to 10# |Negligible |Negligible |
| |lifting and/or carrying such articles as dockets, ledgers and small | | | |
| |tools. Although a sedentary job is defined as one, which involves | | | |
| |sitting, a certain amount of walking and standing is often necessary | | | |
| |in carrying out job duties. Jobs are sedentary if walking and | | | |
| |standing are required only occasionally and other sedentary criteria | | | |
| |are met. | | | |
| |Light: Ability to lift up to 20 pounds maximum with frequent lifting |Up to 20# |Up to 10# or requires |Negligible or constant |
| |and/or carrying of objects weighing up to 10 pounds. Even though the | |significant walking or |push/pull of items of |
| |weight lifted may only be a negligible amount, a job is in this | |standing, or requires |negligible weight |
| |category when it requires walking or standing to a significant degree.| |pushing/pulling of arm/leg | |
| | | |controls | |
| |Medium: Ability to lift up to 50 pounds maximum with frequent |20-50# |10-25# |Negligible-10# |
| |lifting/and or carrying objects weighing up to 25 pounds. | | | |
| |Heavy: Ability to lift up to 100 pounds maximum with frequent lifting |50-100# |25-50# |10-20# |
| |and/or carrying objects weighing up to 50 pounds. | | | |
| |Very Heavy: Ability to lift over 100 pounds with frequent lifting |Over 100# |Over 50# |Over 20# |
| |and/or carrying objects weighing over 50 pounds. | | | |
|List any other physical requirements or bona fide occupational qualifications:| |
Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.
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