Performance Improvement Coord

JOB SPECIFIC RESPONSIBILITIES Designs, develops, formulates and conducts medical and statistical studies for Quality/Risk Assessment and Improvement Program as assigned Reviews patient medical records and/or pertinent information utilizing a criterion - based system and applies the criterion in performing data abstraction Abstracts, collects, and enters data in the appropriate data base; inputs pertinent information in the correct categories timely, including all necessary patient identifiers Implements meaningful performance measures and provides useful data/information and facilitates indicator development with associated targets and benchmarks.

Aggregates, analyzes and organizes data to readily identify opportunities for improvement; communicates performance problems, undesirable variation, and important trends. Provides input to the establishment of measurement criteria for suspected problems. Employs statistical techniques, generates and/or develops clinical/statistical reports, and assures quality, accuracy and integrity of the finished product.

Runs committee meeting reports and/or occurrences as scheduled, prepares and integrates appropriate reports/information timely and accurately. Capable of creating reports utilizing statistical tools such as graphs, charts, tables and other visual aids. Prepares summary reports for clinical/ancillary departments timely and accurately; identifies cases to be reviewed by different committees Compiles QA physician profiles for use in reappraisal process, reappointment and/or renewal/ revision of clinical privileges.

Retrieves and prepares (in suitable format) statistical data in response to requests from different committees and/or other appropriate hospital staff. Able to create reports for high level presentation. Core Measures, Regulatory, and other Summary Reports Reviews patient medical records utilizing a criterion - based system and applies the criterion in performing data abstraction.

Abstracts, collects, and enters data in the appropriate data base. Abstracts, displays, analyzes aggregated information based on pre- approved criteria Creates and/or develops appropriate reports timely and accurately. Identifies opportunities for improvement and collaborates with appropriate department in developing action plan.

Follows up on effectiveness of the implemented plan. Compiles QA physician profiles for use in reappraisal process, reappointment and/or renewal/ revision of clinical privileges. Protects the confidentiality of quality management proceedings and documents; foster due process and conducts activities in accordance with the Healthcare Quality Improvement Act and the Indiana Code.

Enforces policy on release of health care quality data and responds appropriately to requests for information. Maintains data files according to policy. Enforces policy on release of health care quality data and responds to requests for information Assist in the day to day activities of the hospital’s risk/quality management activities/program.

Performs the following duties and responsibilities as per direction of the Director, Quality/Risk Management. Monitors reviews, and track hospital incident reports and coordinates reporting and follow-up with other members, as directed by the Director, Quality/Risk Management. Incorporates necessary events and outcomes in the quality/risk review activities.

Provides the Quality Management Committee/Safety Committee and associated committees with current risk management reports that have an impact on the quality of patient care. Identifies and participates in plans to reduce or eliminate risks related to patient care. Cooperates with managers for risk management functions through mutual sharing of information.

Ensures the confidentiality of the risk data. Coordinates all activities related to potential/actual litigation activities and/or process. Develops and/or assists in developing plan for reducing risk related activities.

Customer Satisfaction Participates in activities related to improving patient satisfaction. Demonstrates professional behavior with hospital and medical staff in order to enhance collaborative relationships necessary to achieve hospital goals. Displays courteous and professional treatment of co – workers; applies team approach to problem solving.

Communicates the mission, ethics and goals of the organization; serves as role model in all actions inside and outside of the hospital. Keeps abreast on current literature, regulatory standards and contemporary methodology related to performance improvement Maintains professional growth and development through inservices, seminars, professional affiliations; participates in continuing education programs, department meetings, and information management systems/principles and/or training.

Other Functions Completes job duties within the required time frame, according to the established schedules or workflow requirements Demonstrates organization in performing several tasks simultaneously; shows willingness to move from one task to another as work requires without being asked. Assists in ensuring the department stays within budget by controlling own expenses. Demonstrates ability to prioritize activities according to urgency or importance on a daily basis.

Performs/assists in other projects as assigned. Participates in continuing education programs, departmental/inservice meetings and information management systems/training principles as required by the department/hospital.