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 facilitating performance enhancement teams, clinical quality groups, FMEA teams, Sentinel Event Alert groups, and Sentinel Event Teams. This position ensures compliance with Joint Commission licensure for the business line, verifying adherence to CMS Conditions of Participation and state licensure requirements. The Specialist is also responsible for managing projects for prioritized teams and initiatives, alongside developing and executing educational programs to bolster the performance improvement process. Additionally, the Specialist provides consultation on performance improvement as needed, communicates ongoing activities, and generates comprehensive reports and presentations. All documentation related to performance improvement activities and responsibilities is meticulously maintained.

Key Responsibilities and Essential Functions

Education and Training
  • a. Create educational resources related to Joint Commission Standards, CMS COPs, State Regulations, and performance improvement methodologies to share with team members.
  • b. Conduct educational sessions focused on the aforementioned topics.
  • c. Develop online learning modules for Home Health topics accessible via Success Factors.
  • d. Maintain thorough records of all educational activities, including attendance, evaluations, and certifications.
  • e. Facilitate the Joint Commission, CMS COP, 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 COPs, State Regulations, and performance improvement processes.
  • b. Conduct regular and random assessments of departments to review compliance with Joint Commission Standards and engage with Managers and staff on progress and outcomes.
  • c. Lead the Joint Commission Triannual survey and State Complaint surveys.
  • d. Keep detailed records of departmental consultations.
Project Management and Facilitation
  • a. Collaborate with leadership to develop team charters.
  • b. Formulate project plans and conduct research on relevant standards and regulations.
  • c. Guide leaders/chairs in utilizing performance improvement tools.
  • d. Create process flowcharts and organize meeting agendas.
  • e. Schedule meetings, notify participants, and prepare necessary documentation.
  • f. Facilitate meetings to ensure objectives are met and maintain attendance records.
  • g. Document meeting minutes and track action plans for effectiveness.
  • h. Communicate team activities to members and leadership, preparing presentations as needed.
  • i. Act as a leader in the absence of the designated chair as required.
Documentation and Communication
  • a. Keep comprehensive records of project and committee activities using appropriate performance improvement forms.
  • b. Document root cause analyses and team activities related to sentinel events.
  • c. Maintain a notebook of hospital measures and performance improvement activities.
  • d. Prepare presentations and reports for assigned responsibilities.
  • e. Ensure readiness for Joint Commission evaluations.
  • f. Organize and conduct the Quarterly PAC meeting for the assigned Home Health committee.
  • g. Develop content for performance improvement display boards.

Required Qualifications

Education: Diploma from an accredited nursing program (Bachelor's Degree preferred) with a current Georgia Registered Nurse License.

Licensure and Certification Requirements

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

Experience Requirements:

  • A minimum of 4 years of experience in Home Health is required, with a preference for knowledge in performance improvement and quality management tools and techniques.
Preferred Skills:

Excellent written and verbal communication skills, proficiency in group presentations, and familiarity with audio/visual setups. Proficient typing skills on Windows-based applications and knowledge of EPIC EMR are essential. Strong organizational, problem-solving, and critical thinking abilities are necessary, along with a detail-oriented approach and positive leadership skills. Understanding of Home Health regulations, industry standards, and licensing requirements is also important.

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