Performance Improvement Coordinator - Quality & Safety

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Work Shift

The Quality & Safety team at Cobb Hospital has an exciting opportunity for a Performance Improvement Coordinator!

Job Summary:

The Performance Improvement Coordinator reports to the business line Executive Director and is responsible for coordinating and facilitating performance improvement teams, clinical quality teams, FMEA teams, Sentinel Event Alert teams and Sentinel Event Teams. Responsible for business line Joint Commission licensure, ensuring the business line meets CMS Conditions of Participations and state licensure. Responsible for project management for assigned priority teams/projects. Responsible for developing and implementing PI education programs to support the PI process. Provides PI consultation as requested. Communicates PI activities. Develops and provides PI reports and presentation. Maintains PI documentation to support assigned PI activities and responsibilities.

Core Responsibilities and Essential Functions:

Education to staff on Joint Commission, CMS, State Regulations, PI initiatives and results.

• a. Develops educational offerings related to Joint Commission Standards, CMS COPs, State Regulations, performance b. improvement philosophy, processes, tools and methodologies to share with team members.
• c. Conducts educational classroom sessions related to above-described offerings.
• d. Develops computer-based learning programs for posting on Success Factors for Home Health related topics.
• e. Maintains documentation of all education records, including attendance rosters, evaluations, test scores, certificates.
• f. Conducts the Joint Commission, CMS COP, State Regulations, PI overview session of Home Health Orientation.

Consultation with direct Home Health team

• a. Conduct consultation sessions with Managers and/or PI Reps for departments as related to Joint Commission Standards and survey preparation, CMS COPs, State Regulations, PI process, tools, methodologies, projects, data/analysis, presentations, and documentation of PI activities.
• b. Conducts scheduled and random rounds to departments to review Joint Commission Standards, CMS COPs, State Regulations, PI materials and talk with Managers and staff regarding progress and outcomes.
• c. Heads up Joint Commission Triannual survey and State Complaint surveys.
• d. Maintains records regarding departments consulted.

Project Management/Facilitation

• a. Develops team charter in collaboration with leadership owner.
• b. Develops project plans.
• c. Conducts research on standards, regulations and/or team/committee topics being addressed.
• d. Coaches leader/chair in tools of PI.
• e. Creates process flowcharts.
• f. Plans meeting agendas and activities with team/committee leader/chair.
• g. Arranges meeting dates, times, locations and notifies members.
• h. Prepares meeting documents.
• i. Facilitates team/committee meeting to keep on track and accomplish meeting objectives.
• j. Maintains attendance roster.
• k. Scribes meeting minutes.
• l. Maintains meeting assignment document.
• m. Develops action plans and measures of effectiveness in collaboration with leader/chair and members.
• n. Tracks progress of action plans and measures of effectiveness and works with team leader/chair to achieve targeted outcomes.
• o. Maintains team/committee documentation records.
• p. Provides communication of team/committee activities to team members, leadership.
• q. Prepares presentations for team leader/committee chair.
• r. Serves as leader in absence of leader/chair as requested.

Documentation

• a. Maintains project/committee/team activities documentation utilizing appropriate PI forms.
• b. Maintains documentation of root cause analysis and team activities related to sentinel events.
• c. Maintains hospital measures and PI activities notebook which contains hospital specific data and department specific measurement inventories, annual PI assessments and quality control inventories.
• d. Prepares presentations and reports for areas of responsibility.
• e. Documents PI project teams using PI forms and tools to support appropriate methodology.
• f. Maintains Joint Commission readiness manual.

Communication

• a. Plans and conducts the Quarterly PAC meeting for assigned Home Health committee.
• b. Develops content material for PI Display Boards.

Performs other duties as assigned

Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

• Bachelors Nursing-Preferred or Accredited Program Nursing

Required Minimum License(s) and Certification(s):

All certifications are required upon hire unless otherwise stated.

• RN - Reg Nurse (Single State) or RN-COMPACT - RN - Multi-state Compact

Required Minimum Experience:

• Minimum 4 years experience in Home Health.

• Tools and techniques of performance improvement/quality management and project management is preferred.

• Supervisory experience is preferred.

Required Minimum Skills:

• Strong written and verbal communication skills, ease, and comfort with group presentations, capable of audio/visual set up and displays.

• Typing skills on Windows based computer applications and familiarity with EPIC EMR.

• Professional, organized, problem solving/critical thinking, a must.

• Must be detail oriented, with excellent organization, positive leadership skills, team building, change management, problem solving, project management.

• Knowledge of Home Health regulations, industry standards, and licensing requirements

Join us and discover the support to do more meaningful workand enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.