Performance Improvement Consultant

Senior Performance Improvement Program Coordinator

This Medical Staff Senior Performance Improvement Program Coordinator utilizes clinical, accreditation standards and quality improvement expertise to manage and coordinate the development and standardization of the medical staff performance evaluation program supporting reappointment, advancement, and clinical quality in compliance with regulatory requirements for provider performance profiles and peer review processes. The Senior Performance Improvement Program Coordinator acts as an integral consultant to enhance performance and quality of providers at Northern Arizona Healthcare.

The position collaborates with the Director Medical Staff Services to promote medical staff performance improvement and standardize work processes within the Medical Staff Services department and orchestrates team efforts to ensure that Performance Improvement Coordinator and Clinical Analyst meet deadlines and expectations. Position includes direct oversight of limited Director duties in Directors absence.

Responsibilities

Data Integrity

• Implementation and responsibility for the development and management of Medical Staff Peer Review programs and oversight of all Medical Staff Performance Programs including, FPPE and OPPE processes.
• Provides comprehensive medical record review of referrals for analysis of standard of care.
• Works directly with the Medical Staff Peer Review committees at Northern Arizona Healthcare in reporting, reviewing and follow-up of cases sent to committee for review assuring peer review process is functional and improves the quality of care by the medical staff.
• Identifies trends in provider behavior and quality of care.
• Oversight of Medical Staff peer review meetings including preparation, minutes and follow-up.
• Ensures data integrity, collection, validation, trending, and reporting to MEC as required.

People Management/ Staff Development

• Coordinate with the Medical Staff Performance Improvement Coordinator & Clinical Analyst to support the effectiveness of the NAH Medical Staff Performance Program.
• Maintains knowledge of all standards and regulations involving medical staff performance data and peer review.
• Create learning opportunities that advance Medical Staff Leadership and Medical Staff Services team.

Performance Management

• Works closely with Medical Staff leadership and Performance Improvement Coordinator and Clinical Analyst to ensure effectiveness of Performance Improvement Program
• Ensures effective roles and processes are developed within the department to support the Performance Improvement Program.
• Assists with limited Director duties in Directors absence.

Department Management

• Responsible for searching external databases and web sites to keep current on all data benchmarks and using data abstraction tools to produce meaningful analyses and correlation of data.
• Maintains proficiency in the use of MDStaff, MIDAS, MDStat, Stat-it and other databases as necessary.

Compliance/Safety

• Responsible for reporting any safety-related incident in a timely fashion through the Midas/RDE tool; attends all safety-related training programs; performs work in a safe manner; monitors work environment for possible safety issues and ensures others are also performing work in a safe manner.
• Stays current and complies with state and federal regulations/statutes and company policies that impact the employee's area of responsibility.
• Completes all company mandatory modules and required job-specific training in the specified time frame.

Qualifications

Education:

Bachelor's Degree- RequiredMaster's Degree- Preferred

Certification and Licensure:

Current RN license in the state of Arizona- RequiredLean Six Sigma (or equivalent process improvement) certification- Preferred

Experience:

Minimum 1 year performance improvement experience- RequiredFive years clinical experience in acute hospital setting- RequiredPrior experience managing or leading staff and teams- RequiredKnowledgeable regarding regulatory and accreditation requirements, CMS at minimum- Required; TJC- PreferredExperience with Cerner, Midas, MDStaff- Preferred

Healthcare is a rapidly changing environment and technology is integrated into almost all aspects of patient care. Computers and other electronic devices are utilized across the organization and throughout each department. Colleagues must have an understanding of computers, and competence in using computers and basic software programs.