Performance Improvement Manager: Job Description



Primary AccountabilityIs responsible for facilitating the improvement of clinical outcomes and will serve as a consultant within the organization in performance improvement and risk reduction practices. Description of Primary Duties & ResponsibilitiesResponsible for the oversight of QI activities and management of InterCare’s clinical data collection and analysis.Utilizes the EHR to identify reporting capabilities and pathways for obtaining data to meet regulatory requirements including but not limited to UDS, MU, TJD, FTCA, and PCMH.Utilizes DRVS for data review and ongoing monitoring of Performance Improvement opportunities. Responsible for data collection, analysis and submission of UDS clinical outcome measures annually. Analyzes data for patterns and trends in care delivery; works on discovering root causes for specific patient care trends.Responsible for the Joint Commission chapter on Performance Improvement.Responsible for policy development and updates in the area of Quality/Performance improvement.Assures completion of all quality and outcome reporting as required by all regulatory pletes high risk procedure audits as part of the re-privileging pletes the annual quality improvement plan and work plan.Assist in the leadership of the corporate QI committee and prepare minutes as required.Functions as InterCare’s consultant to the site PI teams.Trains site multidisciplinary teams on the PDSA cycle.Attends monthly PI team meetings.Supports site teams in the use of data. Supports team leaders in the utilization of the DRVS tool for pulling data reports.Provides clinical input to MIS and EHR clinical in regards to templates, flow, CQM selection, UDS, and PCMH.Works with MIS for customizations required to assure capture of required data elements.Collaborates with EHR clinical to assure workflow and documentation support appropriate data captureWorks with MIS and HER clinical to determine correct mapping for documentation of all required data elements. ????????? Assumes primary responsibility for InterCare’s Event Reporting system.Reviews all events submitted and assures action plans are put in place as needed. Follows up on outstanding events.Serves as the administrator of the Clarity Safety zone portal.Functions as InterCare’s risk reduction coordinator.Responsible for policies and procedures in the area of risk management.Responsible for developing and implementing a systematic approach for managing and minimizing risk throughout the clinic.Assists with the submission of the FTCA deeming applicationIn Conjunction with the Director of CSD conducts annual FMEA.Identifies opportunities for risk education.Collaborates with the CMO and Director of Clinical systems in conducting RCA’s and investigations of AOCC’s.Develops guidelines, recommendations, or implements process improvements to address high areas of vulnerability within the organization.Description of Primary AttributesGeneral DevelopmentDemonstrates the ability to work effectively with a wide variety of people and develop professional working relationships with site staff and other InterCare departments, community members, professional associations, businesses and health care networks.Responds appropriately to teams questions and concerns in a professional manner.Works in close partnership with Leadership staff and coordinates all assigned responsibilities effectively.Possesses skills in motivation, self-direction, and punctuality. Demonstrates a strong work ethic.Demonstrates the ability to work well as part of a team and keep team members updated on current project developments.Demonstrates the ability to think strategically and creatively, juggle multiple priorities, adjust to changing circumstances, organize time efficiently, remain attentive to details and identify resources for projects.Professional and Technical KnowledgePossesses a thorough understanding of theory and practices of quality improvement and clinical health care risk, typically acquired through completion of a bachelor’s degree program in nursing and extensive practical experience in a professional environment.Maintains a working knowledge of clinical outcomes, evidenced based best practice and regulatory requirements.Strives to develop the leadership attributes identified by InterCare’s Management Success Profile. Maintains a working knowledge of?EHR templates and workflow.Technical SkillsProficient in Microsoft Office SuiteAbility to use clerical and numerical skills in preparing final drafts and documents from raw dataAbility to create letters, forms, documents, presentationsAbility to run reports, analyze and interpret data, assist in implementation and maintenance of DRVS database and event reporting munication SkillsPossesses a professional level of written and verbal communication skillsAbility to communicate complex concept in a clear effective mannerPossesses excellent cross cultural communication skills and the ability to communicate to staff members at all levelsPhysical DemandsJob duties are performed in the typical office environment of the organization, which requires ordinary ambulatory skills sufficient to visit other locations. The environmental factors and/or physical requirements of this position include the following: Ability to stand, walk, stoop, kneel, crouch, frequently sit, and lift up to 25 lbsRequires good hand-eye coordination, reach with arms & hands, and finger dexterity, including ability to grasp, and manipulate (using keyboard, office equipment)Visual acuity to use keyboard, operate office equipment, and read printed material and regularly required to talk and hearThis job description in no way states or implies that these are the only duties to be performed by the employee(s) in this position. Employee(s) will be required to follow any other job-related instructions and to perform any other job-related duties requested by any person authorized to give instructions or assignments.I have received and read a copy of my job description and fully understand the requirements._______________________________________________________________SignatureDate ................
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