Performance Improvement Specialist-RN

Job Description Summary As a member of the Quality Management (QM) Department, the Performance Management Specialist is responsible for initiating the design, development, execution and evaluation of performance improvement activities that support the organization’s strategic quality and safety goals. The Performance Management Specialist facilitates multi-disciplinary improvement teams in the review, analysis and recommendation of practice changes and the development and implementation of clinical practice guidelines to enhance patient outcomes. The Performance Management Specialist educates, coaches and supports others in achieving clinical, safety, operational and financial outcome improvements. (Salary Range: 60-100k annually) Job Description Essential Functions 1 - Facilitates the analysis of processes and systems to identify opportunities for improvement and/or development of risk reduction strategies. a) Serves as a facilitator for system-wide improvement projects and special projects as assigned. b) Utilizes appropriate project and quality management principles. c) Develops, implements and maintains mechanisms to track and evaluate the effectiveness of performance improvement initiatives. d) Assists departments in identifying and investigating problems and/or opportunities to improve patient care and services. e) Educates and coaches teams/committees on appropriate project and quality management principles. f) Assures accuracy of data and information provided to departments/committees and other stakeholders; participates in data validation efforts. g) Assists with identification of corrective actions and appropriate monitoring to determine effectiveness. h) Functions as a change agent and facilitates the spread of innovation throughout the organization. i) Assists medical staff in evaluating outcomes, determining areas for improvement and monitoring effectiveness of interventions. j) Provides guidance to operational and medical staff leaders in data analysis, trend identification and problem resolution. k) Contributes to the development of the annual Performance Improvement Program by providing effective reports on the status of projects and identifying quality and safety issues for consideration. 2 -

Contributes to the QM Department’s operational excellence assuring the department delivers quality services in accordance with applicable policies, procedures and professional standards. a) Manages all activities in an efficient, effective and customer-focused manner. b) Ensures services provided meet all applicable regulatory requirements. c) Participates in activities in a manner that ensures operational excellence. d) Assists in the development of operational standards that ensure the work of the department is of the highest quality and meets the organization’s standards. e) Provides support to QM Clinical Outcomes and Data Abstraction staff with the quality assurance / quality improvement case review process, measure abstraction and data submission as needed. 3

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Serves as a resource in developing strategies and indicators to improve care. a) Ensures indicators are based on accepted standards of care and evidence-based medicine. b) Conducts analysis based on best practices (clinical, financial and operational). 4

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Applies LEAN or Six Sigma principles as needed to improve workflows, enhance patient safety, eliminate errors, and reduce redundant processes. 5

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Leads and facilitates multi-disciplinary performance improvement teams; monitors and reports progress of improvement initiatives. 6

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Evaluates the quality and cost factors of performance improvement activities. 7

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Participates in Root Cause Analysis and Failure Mode and Effects Analysis (FMEAs) as required. 8

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Participates in planning, developing, coordinating, and presenting education programs on quality and performance improvement topics. a) Facilitates the incorporation of findings from data analysis into practice changes. b) Presents findings from performance improvement activities at meetings. c) Effectively communicates with other members of the QM Department; shares information with peers within the QM Department related to the relevant work of South Shore Health departments/committees assigned. 9

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Develops procedures to track and compile information and apply appropriate data analysis techniques. a) Researches proposed guidelines using current literature, sample protocols and current practice. 10

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Maintains currency in the quality management field as necessary to meet the organization's mission and, as specified, by federal, state, and any other guidelines/regulations. a) Maintains current nursing licensure and requisite CEU credits as applicable. b) Attends educational sessions as needed to promote further growth and development. c) Attends organization's informational meetings, as assigned. 11

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Achieves all agreed to goals and objectives within specified time frames, as part of the organization’s overall mission. 12

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Technology – Embraces innovation and technological solutions that improve processes and practices. 13

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Safety Awareness – Fosters a “Culture of Safety” through personal ownership and commitment to a safe environment. a) Understands the Joint Commission National Patient Safety Goals and their impact on role. b) Successfully answers safety questions in annual mandatory education program. c) Understands role/responsibility during hospital “Codes”. 14 - Technology and Learning a) Works within legal, regulatory and ethical practice standards relevant to the position. b) Complies with applicable policies and procedures. c) Safeguards the privacy and security of patient information; complies with policies and procedures relating to South Shore Health’s privacy and security programs. d) Brings potential compliance issues to a manager, supervisor, director or VP. e) Complies with the mandatory education requirements of the organization’s compliance, privacy and security programs. Minimum Education

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Preferred Master’s degree in Healthcare Administration, Business Administration, Public Health, Nursing, or other related field. **Nursing Strongly Preferred*** Minimum Work Experience Five years’ experience using quality improvement systems preferred. Experience working with nationally recognized quality and project management tools. Experience conducting studies that determine the effectiveness of processes, personnel, services and their impacts on outcomes. Required additional Knowledge, and Abilities Teamwork/Communication/Time Management

Ability to work collaboratively with others and be a team player Ability to lead and achieve support for change; facilitates innovation and is able to motivate groups towards solution; engages and inspires others Builds credibility and fosters trust of the QM Department Excellent written and oral presentation skills Strong project management skills Highly organized and self-motivated with an ability to multi-task and adapt to various work settings and work autonomously

Project Management/Business Acumen

Expert knowledge of performance improvement and problem-solving methods and tools (e.g., Rapid Cycle PDSA, Six Sigma, etc.) Experience in simulation and process flow analysis Expert knowledge of data collection and data analysis techniques Ability to create basic reports from clinical/financial databases using report writing software Ability to evaluate the quality and cost factors associated with clinical practice improvement activities Robust data analytics skills; demonstrated ability to perform qualitative and quantitative data analyses, translating and communicating data driven insights into clear priorities and interventions Ability to write reports containing technical information Ability to prepare cogent reports and presentations that facilitate decision-making Ability to think analytically and solve complex problems Ability to analyze problems from a systems level Ability to develop and present education programs and/or workshops Expert knowledge of Microsoft Office products; ability to analyze data and create visualizations in Microsoft Excel; familiarity and experience with other visualization tools such as Tableau or Power BI, preferred.

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