Job Description

Location: Good Samaritan Medical Center
Posted Date: 7/3/2020

The performance improvement manager will support the implementation and monitoring of programs and activities designed to ensure that Good Samaritan Medical Center incorporates methods to improve the safe administration of care into all clinical processes, while developing a culture that perceives safety to be of paramount importance.

The Performance Improvement Manager will also be expected to collaborate and provide guidance to hospital staff daily to identify and remove barriers to ensure an error-free clinical and non-clinical setting consistent with defined regulating and accreditation standards (Joint commission, Medicare Conditions of Participation, Departments of Public Health, Mental Health, etc). The Performance Improvement Manager will serve as the hospital's lead to ensure a continuous state of readiness and meeting all Joint Commission, CMS and DPH standards by standardizing processes for evaluation of compliance of standards, identifying opportunities for improvement, implementing changes to hospital operations to meet expected regulatory readiness, measuring effectiveness of interventions with standardized tracer and audit activities.

Key Responsibilities

  • Participates in the development and implementation of hospital and medical staff performance improvement initiatives.
  • Participates as the Hospital’s representative, data collector and reporter in collaborative quality improvement projects both internally and externally.
  • Identifies cases where established criteria are met or not met and reports to appropriate people results in a timely manner.
  • Prepares reports, data and projects to external and internal regulatory entities.
  • Assists the Quality and Patient Safety Team with strategic performance improvement initiatives throughout the hospital.
  • Reports quality measure results to Medical Staff, assists them with interpretation of results.
  • Performs data collection in a timely manner and meets regulatory agencies deadlines for reporting of data.
  • Actively participates in and/or leads committees and meetings that are focused on quality, safety and performance improvement measurements at the direction of the Director of Quality and Safety.
  • Coordinate the regulatory compliance program to meet the standards identified by the TJC, DPH and CMS. Support project structure to insure all staff is involved in regulatory readiness on a daily basis. Works with administrative and clinical leadership to insure they recognize their role in preparation for regulatory readiness. Is supported by the hospital leadership in assuring this process is hospital wide.
  • Is knowledgeable of all standards specific to the Joint commission, CMS, DPH, OSHA, FDA, etc
  • Collects and administers necessary tools and reports to monitor organization’s activities specific to regulatory readiness (tracer rounds, chart audit, etc).
  • Develops a team approach (chapter leaders) to ensure sharing of information and understanding of standards across the organization
  • Identifies and implements educational materials and agendas for all organization stakeholders to ensure continuous regulatory readiness.
  • Develops action plans for all noncompliant standards with measurement of effectiveness.
  • Develops and implements a plan for responding to the arrival of unannounced and announced survey team(s).
  • In coordination with the Director of Quality and Safety and the Risk Manager manages all survey activities from arrival, coordination of survey activities to exit exercises inclusive of successful completion of any action plan associated with the survey process to ensure ongoing accreditation.
  • Ensures the organization is always appraised of all standard changes/updates and implements plans to ensure compliance with changes in a timely manner.
  • As it relates to standards specific to patient safety, provides over-site in the implementation of improved systems for tracking, evaluating, and communicating patterns in patient safety for the hospital.
  • Provide support and guidance to the clinical leadership in meeting the goals within the accreditation and patient safety agenda at the local hospital. Works closely with the system’s clinical leadership, to implement pilot programs designed to eliminate the following: preventable mortality, adverse drug events, falls, pressure ulcers, surgical complications, nosocomial infections, and other patient safety goals as defined by the Joint Commission.
  • Supports the collection of regulatory driven patient safety data for trends and recommend changes, as appropriate, thereby improving the safety of care at the hospital.
  • Reviews and evaluates services to ensure that safety and regulatory recommendations are implemented and desired results are obtained.
  • All other duties as assigned.
  • BS or MS in health care field preferred
  • 5 years in Health Care Quality or Performance Improvement

Application Instructions

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