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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