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Job Description
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COORD PERFORMANCE IMPROV II
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Date: 09/02/2009
Location: Chicago, IL
Facility:TRINITY HOSPITAL
COORD PERFORMANCE IMPROV II - 27181
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SKILLS
(Typing, shorthand and special machinery) s
•Working knowledge of computer operations, report writing, database management, spreadsheets, graphics and statistical tools..
• Excellent communication skills
• Excellent organizational and prioritization skills
• Ability to work with diverse teams and individuals
• Working knowledge of databases and decision support systems.
Knowledge of Transition Systems, and other Severity and/or Risk Adjusted databases and Decision Support Systems
EDUCATION AND EXPERIENCE
• Bachelor of Science Degree in Nursing or Bachelor's
Degree in other related health field.
• 3-5 years experience in research, planning, analysis and utilization review/case management in a healthcare setting.
• Knowledge of Continuous Quality Improvement theory and statistics
• 3-4 years of clinical experience in area of health specialty.
Experience leading teams and facilitating groups
CERTIFICATION
(License, CPA) • RN,
SPECIAL JOB CHARACTERISTICS
(List any featues of the working conditions that might require accommodation for an employee. This may include physical or other requirements of the job such as necessary travel, unusual work hours, lifting, climbing and environmental abnormalities such as adverse, hazardous or unpleasant conditions.) Ability to work under tight time constraints
• Ability to travel locally to other Advocate sites
• Ability to review medical records and computer printouts on a regular basis
• Ability to design visual tools and display
• 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 multiple projects
Job Description:
This individual serves as a consulting staff associate in the Performance Improvement Department. This position is responsible for facilitating interdisciplinary, collaborative performance improvement activities, including medical staff, nursing and clinical support services. This individual works extensively with Risk Management, Patient Safety, Infection Control and Environment of Care to facilitate clinical CQI projects to reduce cost and maintain quality. The associate also facilitates non-clinical, operational improvement teams and manages database systems related to quality and clinical decision support.
A. Provides data consultation and staff support to clinical Quality Improvement Committees, CQI teams and non-clinical, operational improvement teams.
1. Facilitates group process during meetings.
2. Provides guidance and support to team leaders and members to ensure an interdisciplinary, collaborative approach to CQI philosophy, methods and tools.
3. Facilitates CQI teams; provides just-in-time training regarding CQI philosophy, tools and methods.
4. Partners with team leaders to effectively pre-plan meetings, identify best methods to maximize efficiency and outcomes.
5. Provides support to teams including literature search, data collection, statistical data analysis and display.
6. Assists teams in prioritizing and focusing their efforts and designing measurable key quality indicators
7. Assists in development and implementation of action and measurement plans to improve quality and reduce costs.
8. Assists in writing and designing interpretive reports to highlight variations in clinical and non-clinical processes and outcomes for committees and senior leadership
B. Facilitates clinical peer review process and Performance Improvement through active participation in the Medical Staff Peer Review Committees, Functional Committees, Nursing Committees and ad-hoc Committees, as assigned.
1. Acts as internal consultant in providing strategic (non-medical) direction teams and team leaders
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 all regulatory agencies.
4. Provides support to committee chairs which includes consultation on meeting 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) highlighting variations in clinical processes and outcomes and improvement opportunities.
8. Compiles statistical data and reports for use in decision-making by Performance Improvement/Patient Safety Committees, Medical Executive Committee, Medical Staff Leadership, Nursing and Administration, including physician profiles for recredentialing.
9. Assumes responsibility for the coordination of the following Committees and/or departments and services as assigned: Medical Staff Peer Review Committees, Nursing, functional committees and Performance Improvement councils/committees.
C. Supports clinical information systems and preparation of clinical data reports for internal and external customers
1. Acts as System Manager, as requested for MIDAS Plus and Transition Systems and other severity-adjusted databases, as assigned.
2. Develops clinical and statistical information reports out of the appropriate information system to satisfy internal and external customers.
3. Assesses and resolves problems with the software and hardware
4. Ensures reports are prepared and submitted in a timely manner.
5. Assures reliability of reports generated from Information Systems through identification and resolution of problems related to patient care data.
6. Builds clinical process and outcomes data repositories using statistical tools to link defined measures of patient characteristics, process and outcomes.
7. Develops and implements training programs for associates to the MIDAS Plus and Transition Systems software and provides assessment of competency
D. Assists the Director Clinical Excellence in managing the infrastructure for support of process improvement teams and committees.
1. Proposes clinical, operational and administrative projects .
2. Assists Director in planning and providing quality-monitoring reports for Performance Improvement/Patient Safety Committee, Medical Executive Committee, Administration and Governing Council. .
3. Assists the Director in responding to identified quality or regulatory issues and participating in CMS quality improvement projects.
4. Assists in reporting Advocate outcome indicators and participating in system performance improvement initiatives. .
5. Participates in the Sentinel Event/Root Cause Analysis process as needed.
6. Assists in the development and management of projects that employ a systematic method to identify, benchmark, and integrate best demonstrated practice.
7. Coordinates the ORYX project. Responsible for contracting, computer hardware and software installation, education/training and troubleshooting
E. Selection, Development, Motivation and Evaluation of Staff .
1. Evaluates and conducts performance reviews for staff on a timely basis.
2. Assesses educational needs of the staff and facilitates educational opportunities.
3. Assists individuals with identifying professional goals and provides opportunities to achieve those goals
4. Assures all associates understand their role for their processes.
5. Monitor and facilitate the resolution of performance and/or other employee relation issues.
6. Performs appropriate disciplinary procedures according to Advocate policy.
7. Facilitates staff meetings relating to department, hospital and corporate activities.
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