Performance Improvement Specialist

1 week ago

Marietta, Georgia, United States Wellstar Health System Full time
Facility: WAB - Wellstar Administrative Building

Job Overview

The Performance Improvement Specialist is accountable to the Executive Director of the business line and plays a pivotal role in orchestrating and guiding performance enhancement teams, clinical quality groups, FMEA teams, Sentinel Event Alert teams, and Sentinel Event Teams. This position ensures compliance with Joint Commission licensure for the business line, adhering to CMS Conditions of Participation and state licensure requirements. The Specialist is also responsible for managing projects related to prioritized teams and initiatives, as well as developing and executing educational programs to support the performance improvement process. Consultation on performance improvement matters is provided as needed, along with communication of ongoing activities. The Specialist prepares and presents performance improvement reports and maintains documentation to support assigned activities and responsibilities.

Key Responsibilities and Essential Functions

Education and Training for Staff on Joint Commission, CMS, State Regulations, and Performance Improvement Initiatives:
  • a. Create educational resources related to Joint Commission Standards, CMS Conditions of Participation, and state regulations, focusing on performance improvement philosophy, processes, tools, and methodologies for team members.
  • b. Conduct classroom training sessions based on the above offerings.
  • c. Develop e-learning modules for Home Health topics to be accessible on internal platforms.
  • d. Keep comprehensive records of all educational activities, including attendance, evaluations, and certifications.
  • e. Facilitate the Joint Commission, CMS Conditions of Participation, and State Regulations overview during Home Health Orientation.
Consultation with Home Health Teams:
  • a. Provide consultation sessions with Managers and/or Performance Improvement Representatives regarding Joint Commission Standards, survey preparation, CMS Conditions of Participation, state regulations, and performance improvement processes.
  • b. Conduct scheduled and random assessments within departments to review compliance with Joint Commission Standards and discuss progress with Managers and staff.
  • c. Lead Joint Commission Triannual surveys and State Complaint surveys.
  • d. Maintain records of departmental consultations.
Project Management and Facilitation:
  • a. Collaborate with leadership to develop team charters.
  • b. Create detailed project plans.
  • c. Research standards, regulations, and relevant topics for teams/committees.
  • d. Coach leaders/chairs on performance improvement tools.
  • e. Develop process flowcharts to visualize workflows.
  • f. Organize meeting agendas and activities with team leaders.
  • g. Schedule meetings and notify participants.
  • h. Prepare necessary meeting documents.
  • i. Facilitate meetings to ensure objectives are met.
  • j. Maintain attendance records and document meeting minutes.
  • k. Develop action plans and effectiveness measures in collaboration with team leaders.
  • l. Track progress of action plans and collaborate with team leaders to achieve desired outcomes.
  • m. Maintain documentation of team activities.
  • n. Communicate team activities to members and leadership.
  • o. Prepare presentations for team leaders.
  • p. Assume leadership in the absence of the designated leader/chair as required.
Documentation:
  • a. Maintain comprehensive documentation of project and committee activities using appropriate performance improvement forms.
  • b. Document root cause analyses and activities related to sentinel events.
  • c. Keep a detailed notebook of hospital measures and performance improvement activities, including specific data and departmental measurement inventories.
  • d. Prepare reports and presentations for areas of responsibility.
  • e. Utilize performance improvement forms and tools to document project teams effectively.
  • f. Maintain a readiness manual for Joint Commission compliance.
Communication:
  • a. Organize and conduct quarterly meetings for the assigned Home Health committee.
  • b. Develop content for performance improvement display boards.

Required Minimum Education

A diploma from an accredited nursing program with a current Georgia Registered Nurse License is required (Bachelor's Degree preferred).

Required Minimum License(s) and Certification(s)

All certifications must be obtained upon hire unless otherwise specified:
  • Registered Nurse (Single State) or RN - Multi-state Compact

Additional License(s) and Certification(s)

Required Minimum Experience:

  • A minimum of 4 years of experience in Home Health is required, with familiarity in performance improvement/quality management and project management preferred.

Supervisory Experience Preferred

Required Minimum Skills:

Strong written and verbal communication skills, comfort with group presentations, and proficiency in audio/visual setups. Proficient typing skills on Windows-based applications and familiarity with EPIC EMR are essential. Must demonstrate professionalism, organization, problem-solving, critical thinking, attention to detail, and effective leadership skills. Knowledge of Home Health regulations, industry standards, and licensing requirements is crucial.

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