POSITION PURPOSE: Coordinates and supervises organization-wide performance improvement activities, ensuring regulatory compliance and dissemination of results. Serves as a liaison for performance improvement and patient safety activities between the medical staff, administration, department managers, facilitators and other employees.
Responsible for planning, implementation, coordination and reporting of performance improvement functions across the organization, ensuring consistency within the organization as well as with performance measurement principles and accrediting agency standards.
Selects, develops and/or monitors performance indicators. Collects and analyzes data, identify areas of improvement, develops plan for improvement, implements processes and evaluates data for improvement.
Review and initiate investigation of safety/quality reports. Utilizes problem-solving methodology; root cause analysis (RCA), and/or Failure, Mode, Effects & Analysis (FMEA) as appropriate.
Researches possible solutions and encourages others to identify opportunities associated with clinical activities to improve patient care according to standards of practice.
Participates in and coordinates activities for Performance Improvement committees, including meeting preparation, setting agendas, writing minutes, and following-up with action items.
Coordinates process for charter and implementation of performance improvement teams and failure, modes, effects, and analysis teams.
Coordinates participation, team selection and rapid cycle change through external collaborative improvement projects with organizations such as IHI, IHA, and IFQHC.
Assist, monitor and conduct quality improvement activities and performance improvement plans related to state and accreditation activities (Joint Commission, IDPH, CMS).
Provides resources and organization-wide educational programs to promote staff development in performance improvement, including new employee orientation. Provides individual or group consultation as requested.
Facilitates the growth of hospital knowledge regarding quality and high reliability, including the dissemination and implementation of “best practices” across the facility.
Regularly attends Medical Staff Committee and organizational committees to report quality initiatives and outcomes as well as serve as a quality consultant.
Works effectively and professionally as a team member in conjunction with management staff and other department employees
SPECIALIZED KNOW-HOW & REQUIREMENTS
Bachelor’s degree in Nursing, Public Health, Health Care Administration, or other healthcare related field required. Healthcare or previous Quality/Process Improvement experience preferred.
Certified Professional in Healthcare Quality (CPHQ) or ability to sit for CPHQ exam within 2 years of accepting position required.
Significant body of knowledge in performance improvement theory and statistical analysis as well as general body of knowledge in healthcare regulatory standards recommended.
Excellent interpersonal, organizational, oral and written communication skills required.
Experience utilizing Word, PowerPoint, Excel, and electronic medical record system.
Able to organize, prioritize and work independently as well as schedule and produce work in a timely manner.
Strong team-based, results oriented and problem-solving skills a must.
Additional Salary Information: Based on experience in healthcare and/or experience in quality/patient safety.
Internal Number: 1
About CGH Medical Center
CGH Medical Center is a progressive acute care 99 bed facility located in Sterling, IL, a part of the Rock River Valley region of Northern Illinois. CGH Medical Center is accredited by Joint Commission and committed to continuous improvement of the patient experience. With just under 1600 employees, our mission is to: Deliver exceptional patient care by combining outstanding skill with heartfelt compassion. CGH Medical Center offers comprehensive benefits and salary based on skills and experience.