Performance Improvement Coordinator
P OSITION S UMMARY
The Performance Improvement Coordinator helps coordinate the development, implementation, and
evaluation of Mission Community Hospital's overall performance improvement program. This
includes but is not limited to the following activities: 1) supporting the organization's performance
improvement process, 2) identifying performance trends, as well as prioritizing, and recommending
improvements; 3) investigating and tracking risk management incidents and 4) preparing selected PI
reports for committee meetings. The PI Coordinator also plays a supportive role in ensuring
compliance with accreditation and regulatory standards. The PI Coordinator reports to the
Performance Improvement Director.
M AJOR R ESPONSIBILITIES
SERVICE PERFORMANCE
1. Greets/acknowledges customers warmly, with a smile, and immediately when they enter
department/unit/area.
2. Asks how the customer may be helped with interest and concern.
3. Listens attentively, does not interrupt.
4. Accepts ownership and takes action to resolve customer needs and/or concerns.
5. Is attentive and responsive to the expectations of physicians and co-workers.
6. Accepts constructive criticism and modifies actions accordingly.
7. Is generous in acknowledging a job well done.
8. Uses words and behaviors that express consideration, concern and respect.
9. Facilitates and holds staff accountable for meeting department customer service standards in the
performance of duties.
10. Utilizes telephone skills effectively as outlined in the Star Service Program.
11. Keeps all private information about staff or patients confidential.
12. Identifies customers and their service requirements.
13. Meets or exceeds customer service improvement targets as demonstrated by dashboards, etc.VALUE ADDED - INCREASES WORTH OF SERVICE TO MISSION COMMUNITY
HOSPITAL
1. Participates in marketing activities of the Hospital including but not limited to committees/task
forces, speaking engagements, conducting tours, Hospital sponsored health fairs.
2. Contributes to marketing materials such as brochures, newsletters, teaching materials.
3. Participates in staff recognition activities in ways that reward behaviors reflecting positively on
Mission Community Hospital.
4. Engages in interdepartmental / multi-department/house-wide process improvement
forums/taskforce/committees.
5. Offers and implements solutions to challenges/problems.
6. Assist with the development-related activities including fund raising programs and activities.
7. Monitors the marketplace and recommends new and creative business opportunities.
8. Analyzes targeted existing services and product lines for cost/benefit and develops appropriate
strategies to improve growth where applicable.
9. Attends/participates in activities that contribute to professional growth and development.
SPECIFIC DUTIES AND RESPONSABILITIES
1. Responsible for coordinating, facilitating, and reporting hospital-wide PI activities/initiatives
including inpatient and outpatient Core Measure data abstraction.
2. Responsible for assisting with coordinating and facilitating hospital-wide accreditation and
regulatory agency survey preparedness and readiness.
3. Implement performance improvement processes that lead to a positive and measurable patient care
and service impact.
4. Establishes a continuous performance and quality improvement effort and monitoring
and reporting system. Regularly reports the status of performance and quality
improvement efforts and impacts.
5. Reviews QualityNet website on a regular basis to keep abreast of new changes and
updates. Ensures requested information/data is submitted before deadlines.
6. Ensures needed PI data is collected and analyzed on a timely basis and makes recommendations
for future patient care and organization improvements based on the data.
7. Searches out best performance and quality improvement practices, making department leaders
aware of them, and suggesting areas where they could be implemented.8. Assist the Director of PI in coordinating the Quality Council. Develops and analyzes performance
improvement data for tile council, designs and implements the necessary Quality Council
processes and systems.
9. Assist the Director of PI in conducting a minimum of one failure mode and effects analysis
annually and reporting findings to appropriate senior management and PI committees.
10. Assist the Director of PI in conducting and/or facilitating a minimum of two Root Cause Analysis
(RCA) annually and reporting findings to appropriate senior management and PI committees.
11. Assist the Director of PI in coordinating and facilitating peer review activities as needed.
12. Assures policy and procedure standards comply with local, state, and federal law and regulatory
requirements.
13. Recommends changes in the administrative policies that conform to accreditation standards and
California/Federal regulations.
14. Assist with developing and implementing policies and procedures that support the provision of
services.
15. Submits accurate and timely status reports to the Director of Pl and/or hospital committees as
required.
16. Assists the Director of PI to ensure that mechanisms are in place for ongoing data collection,
analysis and reporting for important processes and outcomes throughout the organization in order
to maintain and improve the quality of patient care and services.
17. Identifies and reports national/regional benchmarks or outcomes excellence targets that assist in
identifying/supporting performance improvement opportunities.
18. Uses a disciplined process improvement method (the FOCUS-PDCA methodology- identifies the
process, barriers to outcomes and corrective action plans) and performance improvement tools.
19. Assists the Director of Pl in assuring that process improvement teams and committees develop
strategies (based on their monitoring activities) to improve patient care outcomes by assuring that
hospital practices reflect the best known science; that best practices are identified and emulated;
that variations in clinical care processes are reduced; that reversible causes of patient care
complications are identified and reduced or eliminated and that DRG specific patient outcomes are
both measured and continuously improved, including but not limited to FEMA, patient safety
initiatives, clinical pathways, restraint management, code blue effectiveness/ outcomes, staffing
effectiveness, DHS corrective actions plans.
20. Collects, trends, reports and displays baseline and concurrent outcomes data demonstrating
effectiveness of action plans as compared to national/regional benchmarks or outcomes excellence
targets.
21. Coordinates, manages and keeps accurate records/files for large volume of information that
includes data collection; aggregation and display of information: statistics• the dissemination of
information to appropriate committees and personnel; reports; corrective action plans status '
resolution; follow-up activities.22. Possess and maintains a working knowledge of Joint Commission standards, State of
California laws and statutes (e.g., Title XXII), CMS regulations, policies and procedures,
and community standards.
23. Evaluates, monitors, and sustains compliance with accreditation and regulatory bodies.
24. Coordinates MCH's continuous readiness for the Joint Commission, DHS and CMS surveys
in collaboration with the Performance Improvement.
25. Performs other duties as related or assigned.
COMPLIANCE
1. Completes unusual occurrence forms within 24 hours of event, if not completed by
department director/manager/supervisor.
2. Reports, promptly. any suspected or potential violations to laws, regulations, procedures,
policies and practices, and cooperates with investigations.
3. Conducts all transactions in compliance with all corporate and medical center policies,
procedures, standards and practices.
4. Facilitates/fosters compliance with all applicable laws, regulations, procedures, policies
and practices required by the job, based on the scope of practice of the position.
5. Facilitates identification and reporting of occurrences of potential liability to the Hospital.
INFORMATION MANAGEMENT
1. Uses information sources appropriately in department/unit operations.
2. Uses department specific information systems applications efficiently and effectively.
3. Accesses and creates department specific information system application reports.
4. Conducts reality and validation assessments of data processed by the department.
5. Serves as an effective resource to IS to ensure accurate entry/updating of department specific
systems applications.
6. Complies with hospital policies, accreditation agency standards and state and federal
confidentiality requirements related to management of information, including HIPAA.
7. Obtains necessary training prior to initial equipment and software use.
8. Uses software at an intermediate to advanced level.
Work Place Responsibility : Maintains a safe and healthy working environment.
Work Condition Work is performed in an office setting and requires no hand-on patient care.
QUALIFICATIONS
1. Current California RN license required
2. Minimum of BSN degree preferred
3. Minimum two years acute hospital nursing experience required.
4. Two years performance improvement/outcomes management experience in acute care setting
preferred.
5. High level of knowledge related to Joint Commission hospital accreditation standards, Department
of Health and Human Services and the Centers for Medicare and Medicaid Services regulations.
6. Certified Professional in Healthcare Quality (CPHQ) preferred.
7. Excellent English written/verbal communication skills.
8. Computer skilled with experience using Microsoft Office software at an intermediate level.
9. Intermediate to advanced level Microsoft Excel database and statistical analysis skills required.
