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Sr Spec-PI-Quality / Safety / Sharp Grossmont Hospital / Full Time / Days

Job ID JR126462 Date Posted 07/28/2022
La Mesa, California
  • Grossmont Hospital
  • Day
  • Regular
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Shift Start Time:

8 AM

Shift End Time:

5 PM

Additional Shift Information:

Weekend Requirements:

No Weekends

On-Call Required:


What You Will Do
The purpose of the Sr. Performance Improvement Specialist is to improve clinical outcomes including responsibilities relating to leading teams in the utilization of Change Acceleration Process and PI tools and providing feedback to physicians, managers, directors and executives. In collaboration with the Chief Medical Officer and appropriate Supervisory Committee Chair, facilitates evaluation of the medical staff's quality of care and leads improvement projects to decrease variation in physician practice to improve clinical outcomes and reduce cost. Assists the hospital service lines, operational areas and medical staff in identifying real and potential quality issues through measurement and analysis along with concurrent and retrospective review of performance information. Assists with operational planning and development of the hospital quality/safety plan; provides daily work direction to support staff to achieve objectives of the quality/safety plan.

Required Qualifications

  • Bachelor's Degree in Nursing Or
  • Bachelor's Degree In an appropriate health related field.
  • 3 Years Experience in healthcare performance improvement/quality/patient safety.
  • Experience with interacting (in both oral and written forms) with staff, leaders, physicians, patients and families.
  • Experienced with designing and managing data collection as well as analyzing, interpreting and presenting clinical quality-related data.
  • Previous case review experience.

Preferred Qualifications

  • Master's Degree In related field.
  • 5 Years Clinical experience as a licensed professional.
  • Certified Professional in Healthcare Quality (CPHQ) - National Association for Healthcare Quality -PREFERRED
  • Certified Professional in Healthcare Risk Management (CPHRM) - American Hospital Association -PREFERRED
  • Certified Professional in Patient Safety (CPPS) - Certification Board for Professionals in Patient Safety -PREFERRED
  • California Registered Nurse (RN) - CA Board of Registered Nursing -PREFERRED

Other Qualification Requirements

  • Current unencumbered CA license appropriate to requirements of position. Six Sigma Green Belt Certification is preferred. The department is responsible for tracking and maintaining this certification.

Essential Functions

  • Department performance improvement
    Department and Division Performance Improvement
    Takes initiative to identify opportunities and improve department effectiveness, including work flow redesign, workload distribution and prioritization; and improvements in data systems and processes.
    Works collaboratively and effectively with team members to establish and achieve goals.
    Actively participates in system and departmental meetings as well as interdisciplinary collaborative work efforts.
    Assists other department staff with prioritization of workload.
    Completes other assigned projects including unanticipated urgent assignments.
  • Leadership
    Demonstrates strong communication skills (verbal and written), presentation skills and patience with individuals at all levels of the organization.
    Shares expertise and tools with colleagues; seeks opportunities to foster success in others.
    Assumes responsibilities for own professional development by attending courses and at the request of leadership, seeking continuing education to enhance job function and stay abreast of industry and regulatory changes.
    Manages quality and patient safety issues in the absence of the director, including follow through on time critical events and requests.
    Provides education and technical support specifically for the development, implementation and maintenance of PI activities and Yellow Belt Workshops and other educational offerings as appropriate. Reinforces Lean Six Sigma Principles through on-going educational offerings.
  • Performance Improvement
    Medical Staff Performance Improvement
    Facilitates provision of provider-specific profiles to be utilized for ongoing professional practice evaluation and re-credentialing.
    Collaborates with physician leadership to establish meaningful peer review criteria and provider-specific performance indicators. Uses data to evaluate and refine at least annually.
    Coordinates the peer process in an accurate, timely and confidential manner, ensuring appropriate fact-gathering and case presentation. Optimizes use of available data sources (e.g. RCA findings, mortality reviews, code blue reviews).
    Coordinates the case review process, including performing case reviews and directing the assignment and completion of high quality reviews by others.
    Coordinates the Behavioral Variance Reporting (BVR) process in a timely and confidential manner, ensuring appropriate fact-gathering and referral to leadership.
    Collaborates with analytical resources and physician leadership to identify and leverage data sources for meaningful analysis to drive improvements in provider practice and reductions in practice variation.
    Conducts effective interviews with physicians involved in safety events to identify system failure modes.
    Facilitate performance improvement in response to opportunities identified.
  • Project management
    Leads Performance Improvement Projects

    Identifies Opportunities for Improvement:
    Utilizes independent judgment, training and clinical experience to recognize practice variation and opportunities for improvement.
    Performs surveillance of multiple data sources, benchmarks & literature to identify improvement opportunities.

    Conducts Project Management:
    Creates and negotiates the project charter with the project sponsor and process owner, including team, scope, resources, metrics, goals, timelines, communication plan, project transition, and project closure.
    Utilizes appropriate performance improvement tools and processes (DMAIC, Lean, CAP) to drive improvements in entity, department, and physician performance.
    Translates customer feedback into project focus areas using Six Sigma tools, and establishes key project metrics that relate to the voice of the customer and yield process insights.
    Leads comprehensive systematic analysis (e.g. FMEAs).
    Ensures rigor in project execution, phase requirements and timing. Presents meaningful analysis of barriers to progress and recommends mitigation strategies. Organizes and facilitates project phase reviews with appropriate leaders to ensure adherence to project plan and timeline.
    Develops effective project control monitoring and hand-off strategies. Assist process owners, as needed, with control monitoring and adoption of continuous improvement culture.
    Selects the appropriate metrics for projects and applies measurement systems analysis to determine and ensure accurate measurement of causes and effects.

    Manages Change:
    Coaches others on effective use of change management tools to ensure success in PI projects.
    Understands and applies techniques/tools for managing organizational change using change acceleration process (CAP) including identifying appropriate leaders, understanding existing systems and structures, creating a shared need, shaping a vision, mobilizing commitment, making change last and monitoring progress.
    Identifies and effectively manages human resistance to change.
    Uses effective and appropriate communication techniques for different situations to overcome organizational barriers to success.

    Facilitates Teams:
    Leads and facilitates implementation work teams based on organizational priorities and ensures projects are completed and ongoing data collection is managed and documented as needed.
    Defines, selects, and applies techniques that support and sustain team member participation and commitment (nominal group, brainstorming, etc.).
    Applies coaching, mentoring, and facilitation techniques to guide a team and overcome problems.
    Works through sponsor and process owner to ensure accountability and effective follow-through of team members in order to achieve project timelines and goals.

    Utilizes Data:
    Ensures accuracy and integrity of data.
    Identifies statistical trends in data through utilization of independent judgment, training and clinical experience in analysis of case reviews, system reviews, and/or of clinical data.
    Conducts accurate, comprehensive and systematic reviews of ongoing measurement of operational process and outcome data through utilization of independent judgment, training and clinical experience.
    Manages the design and completion of needed data collection, analysis & reporting in compliance with department/system or applicable regulatory standards and measurement specifications. Ensure timely and accurate completion.
    Effectively uses ongoing monitoring techniques to sustain improved processes.
    Aggregates and presents professional reports and meaningful data analysis to audiences of all levels.
    Maintains confidentiality of quality improvement department information. Refer to quality confidentiality agreement.

Knowledge, Skills, and Abilities

  • Current knowledge of JC, State and Federal regulatory agency requirements, standards and regulations, particularly those related to PI, required.
  • Intermediate computer skills required including working knowledge of PowerPoint, spreadsheets, statistics, and clinical information systems.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class

Certified Professional in Healthcare Quality (CPHQ) - National Association for Healthcare Quality; Certified Professional in Healthcare Risk Management (CPHRM) - American Hospital Association; Master's Degree; Certified Professional in Patient Safety (CPPS) - Certification Board for Professionals in Patient Safety; California Registered Nurse (RN) - CA Board of Registered Nursing; Bachelor's Degree in Nursing; Bachelor's Degree
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