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Director of Performance Improvement

Overview Our Director of Performance Improvement is responsible for management and administration of facility's quality and performance improvement activities. Overall responsibilities include providing technical assistance to facility leaders for the development and implementation of processes and systems to deliver safe and quality care and services that comply with licensing and regulatory standards, coordinating data collection, tracking and trending, and the monitoring of performance indicators. Qualifications Education:  A Bachelor's degreerequired in human services, health care field, management, or related field. Master's Degree preferred. Experience:  Three (3) years of experience in a performance improvement, quality assurance, or contract management related position. Experience in healthcare, correctional, security, forensic facility or secure setting preferred.  Demonstrated experience in performing tasks related to process design, management and improvement; systems analysis; data collection, analysis and reporting; and other tasks requiring general management and leadership skills may be substituted on a year for year basis for experience in a direct performance improvement, quality assurance, or contract management position.  Experience working with accreditation or regulatory standards desirable.  Experience with Six Sigma or LEAN process improvement methodologies desirable.  CPHQ, Six Sigma or other quality professional certification preferred.  Excellent written, verbal, and computer skills.  Experience with Microsoft Office, especially Excel, required. Experience with data analysis software desirable Licenses/Certifications:  None required.   Responsibilities Directs facility-wide performance improvement activities to achieve demonstrated best practice patient care and safety outcomes. Assists facility leaders to design and implement programs, policies, and practices to insure the provision of medical and mental health care services to patients, insuring that these services are provided in a safe, secure, efficient, economical and effective manner and that they meet all DOC contract requirements and are in compliance with applicable accreditation standards, HIPAA regulations, PREA, and all applicable federal, state and local statutes pertaining to the operation of the facility. Provides training and direct support to departments, committees, PI teams and facility leadership to utilize appropriate data collection analysis methods and tools to measure processes and outcomes, assess performance, identify opportunities for improvement and follow-up with identified actions. Monitors indicator reports to track trends and ensure that significant trends are being reported to executive management in a concise format and are being addressed in a timely manner. Assures that high risk, problem prone issues are addressed, with the relevant Department Head (s), through the PDSA or DMAIC process. Coordinates efforts with DOC Office of Strategic Planning when necessary. Directs initiatives to reduce medical/healthcare errors, serious injuries and other adverse patient outcomes. Facilitate continuous process improvement as a component of each event including leading RCA activities and assuring documentation to memorialize these. Provides training to staff on PI methods, tools, team approaches, root cause analysis, and project presentations.  Coordinates processes for timely development and revision of policies and procedures by designated managers and for review and approval by BSH Hospital Administrator, CCRS Corporate and DOC. Facilitates the development and implementation of internal facility self-assessments and audits to monitor ongoing performance of facility processes and their effectiveness in achieving desired outcomes. Cross-trains with and serves as back-up to the Director of Compliance and Accreditation Coordinates on external audit activities and the preparation and submission of response/corrective action plans and follow-up with BSH and DOC contractaudits, corporate audits, and audits or inspections by any accreditation/regulatory bodies. Serves as back up to the Director of Compliance/Accreditation to conduct inspections and reviews to validate service provision according to contract requirements, regulatory standards and applicable policies and procedures. Coordinates the development and execution of patient, staff, and other stakeholders' satisfaction surveys when requested and ensures that results are aggregated, analyzed and reported to facility leadership for appropriate follow up. Reviews, investigates and reports on events at the facility. Investigates allegations of patients' rights violations, abuse, neglect, and exploitation, and EEO investigations when assigned. Tracks and trends all incident reports and summarizes data monthly for analysis by leadership, participates in mortality and morbidity reviews and conducts root cause analysis on high risk activities as assigned. Must be able to apply principles of critical thinking to a variety of practical and emergent situations and accurately follow standardized procedures that may call for deviations. Must be able to apply sound judgment beyond a specific set of instructions and apply knowledge to different factual situations. Must be alert at all times; pay close attention to details. Must be able to work under stress on a regular or continuous basis. Perform other duties as assigned.
Salary Range: NA
Minimum Qualification
Less than 5 years

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