Summary

The Performance Improvement Specialist is responsible for collaborating with physicians and Chesapeake Regional Healthcare staff to meet CMS/CRH performance improvement priorities and assist with achieving nursing and/or hospital quality performance improvement goals. Provides expertise in performance improvement and causal analysis methodologies. The Performance Improvement Specialist also performs project-based chart reviews, benchmarking activities, and staff education in support of performance improvement and patient safety initiatives.

Essential Duties and Responsibilities

These duties and responsibilities described below represent the general tasks performed on a daily basis; other tasks may be assigned.

• Working with the department leadership, review reports, data, and other analytical materials to assess the effectiveness of PI teams and patient safety initiatives.
• Monitor and support the progress of performance improvement (PI) and patient safety initiatives reporting to the Quality Committee and/or other designated oversight committees.
• Lead and/or assist with multidisciplinary PI teams and causal analysis teams.
• Assist Mortality Committee Medical Chair with Committee data management.
• Provides ongoing data analysis and trending of relevant Mortality data, sepsis data, falls, nursing peer review, and other patient safety data as needed.
• Collaborate with Quality department staff, leaders, medical staff, and others to meet established CRH performance improvement goals.
• Maintain expertise with internal analytic systems in support of department and organizational goals.
• Complete quarterly opportunity analysis and implement improvement plans or PI teams as needed.
• Assist with staff education related to quality and process improvement functions and quality tools and methodologies.
• Serve as a back-up for the ACHC performance improvement chapter.
• Assist with preparing FPPE and OPPE reports, and data analysis as needed.
• Provide staff education related to Excel, PPT, Word.
• Assist with quality measure data pull for designated contracted services.
• Other duties as assigned to include coverage of essential departmental functions and services.
• Actively participate as the department representative on designated multidisciplinary teams and committees.
• Support clinical operations and clinical initiatives as assigned.
• Attend required hospital-wide orientations, meetings, and in-services.
• Demonstrate a commitment to flexible work scheduling when necessary to ensure patient care.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and Experience

Minimum Required Education: Bachelors’ degree in Computer Science, Mathematics, Business or Nursing. Healthcare experience required. Experience in lieu of degree may be considered.

Preferred Education: BSN

Experience: 2+ years of directly related experience

Basic knowledge of concepts, practices, and procedures related to quality and process improvement functions

and quality tools and methodologies, to include casual analysis activities. Proficiency in business software to include Excel,

PowerPoint, and Word.

Certificates, Licenses, Registrations

Green Belt certification preferred. Experience or training in lieu of certification may be considered.

Green Belt certification required within one (1) year of hire.