Employment Type:

Shift:

Description:

Role Summary

Supports and promotes continuous performance improvement and the Trinity Health Leadership System throughout the network. Assists with the Plan, Do, Study, and Adjust (PDSA) stages of performance improvement activities.  Coach for staff at all levels in the PDSA improvement process. Leads Rapid Improvement Events (RIEs). Performs analyses of process data. 

Is familiar with regulatory/ accreditation requirements, Joint Commission, DNV and Department of Health (DOH) agency standards.  Is familiar with CMS and other reporting requirements.

Role Responsibilities and Accountabilities:

• Adheres to established network policies and procedures related to job function.
• Adheres to hospital confidentiality statement. Maintains confidentiality of all phases of the performance improvement process related to patients, physicians, staff and visitors.
• Adheres to safety standards within the network and performance improvement service.
• Aggregates and analyzes collected data to measure performance with established criteria
• Participates as an internal auditor for hospital and regulatory groups
• Applies knowledge of the performance improvement process to determine improvement priorities.
• Assists with new policies and procedures as change dictates related to the Performance Improvement Department.
• Collaborates with network staff to establish criteria for data to be aggregated, compared and reviewed.
• Participates in the development of educational materials for Quality initiatives within the network.
• Ensures teams are data driven and outcome oriented.
• Inputs data timely and accurately.
• Reports performance improvement activities to the Department manager, Director and appropriate clinical teams.
• Reviews available literature to obtain pertinent information as it relates to the performance improvement process and seeks best practice measures
• Serves as a resource to Quality and Peer Review and Organizational teams.
• Serves as an ad hoc resource on Core Measure/Data Base teams.
• Understands and utilizes statistical principles when analyzing
• Identifies opportunities for improvement and/or variance in practice patterns.
• Utilizes national/local benchmarks to analyze data.

• Utilizes PC applications to manage, analyze and display data.
• Works collaboratively with PI Department analyst and Decision Support team to prepare quality and operational data.

Education, Training, Certification and Licensure:

• Baccalaureate Degree in nursing or health related field required.
• Registered Nurse/equivalent clinical experience OR 3+ years industrial experience in a process improvement setting.
• Certified Professional in Healthcare Quality (CPHQ) preferred. Required to obtain within 2 years of date of hire.
• Maintains all licensures and certifications according to NYS regulations and specialty area requirements.
• Participates in continuing education and updates and maintains knowledge and skills related to specific areas of expertise.

Experience and Skills

• Excellent written and oral communication skills.
• Strong interpersonal skills.
• Knowledge of computer applications, such as MS office. 
• Skill in using statistical software. 
• Demonstrated skill in the acquisition, management and display of data.
• Ability to build rapport and coach from the front-line staff.
• Demonstrated ability to manage and introduce change into an organization.
• Specialty credentialing & educational degree according to clinical practice specialty

Specific Areas of Specialization within the Performance Excellence Consultant position exist.

These include:

• Regulatory Readiness: Applies DNV accreditation requirements to performance improvement activities; schedules/ monitors internal audits.
• ED and Critical Care Quality Improvement to include: Sepsis – Inpatient; meets with hospital staff, physicians and others involved in education, tracking and follow-up of sepsis data and reporting.
• Peer Review: Coordination with Risk/ Safety to refer cases to physicians, support specific physician meeting groups and follow up on activities recommended; maintains database documentation.
• Clinical Integration: Special PI projects involving specific units and applying PI tools to unit activities; leadership in other network initiatives such as hand hygiene, ethics.
• Responsibilities may include work with Potentially Preventable Complications (PPC), Potentially Preventable Readmissions (PPR), AHRQ and other specialty specific measures (i.e.- STS, ACC) data.
• Analytics: Development and analysis of clinical outcomes aimed at improving quality of care.

Mission Statement:

• We, St Joseph's Health and Trinity Health, serve together in the spirit of the Gospel as a compassionate and transforming healing presence within our communities.

Vision:

• To be world-renowned for passionate patient care and outstanding clinical outcomes.

Core Values:

• In the spirit of good Stewardship, we heal by practicing Justice in fostering right relationships to promote common good, Reverence in honoring the dignity of every person, Excellence in expecting the best of ourselves and others; Integrity in being faithful to who we say we are.

Work Environment and Hazards:

• Office setting. Exposure class II: service specific, limited exposure to situation which could cause serious illness or injury.

Physical Demands:

• Light work: walking, sitting and standing, walking, lifting, pulling, pushing, and carrying. Exposure to a CRT and repetitive motions (data entry).

Work Contact Group:         

• All services, medical staff, patients, visitors, and various regulatory and professional agencies.
  
  

The above statements are intended to describe the general nature & level of work being performed by persons assigned to this classification.  They are not to be construed as an exhaustive list of duties so assigned.

Pay Range: $39.45 - $59.20

Pay is based on experience, skills, and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.