QUALITY PERFORMANCE IMPROVEMENT MANAGER - Trinity Health : Job Details

**Employment Type:**

Full time

**Shift:**

Day Shift

**Description:**

**GENERAL SUMMARY AND PURPOSE:**

This position oversees the Quality Department at the assigned Saint Alphonsus Medical Center and the Performance Improvement Group for Saint Alphonsus Health System (SAHS). Responsible for contributing to the planning, developing, implementing, and evaluating the overall SAHS Quality and Performance Improvement (QAPI) program.

Fosters and supports a culture of continuous improvement and coordinates the systematic implementation of effective practices designed to reduce error and improve patient outcomes cohesively across the system. Work collaboratively with leadership, management, medical staff, and interdisciplinary staff across the entire organization to develop performance improvement priorities. Responsible for data oversight contributing to multiple publicly reported/regulatory entities, including Leapfrog, CMS submissions (eCQMs, perinatal safety measures, promoting interoperability, etc.), and NDNQI submissions with analysis for the entire system. Provides day-to-day oversight of the programs including personnel management, deployment of resources, project management, evaluation of processes, analysis of data, and continuous regulatory readiness.

**SKILLS, KNOWLEDGE, EDUCATION AND EXPERIENCE:**

Must possess a comprehensive knowledge of performance improvement methodology, data analysis and project management, normally obtained through a bachelor's degree in healthcare related field, with five (5) years of quality or regulatory experience or an equivalent combination of education and experience.

Two (2) years of supervisory experience required. Experience in data collection and analysis within healthcare organizations. Performance improvement methodology and Lean experience preferred.

**ESSENTIAL FUNCTIONS:**

Knows, understands, incorporates, and demonstrates the Organization's Mission, Vision, and Values in behaviors, practices, and decisions. Oversees the processes to assure that performance metrics required by payers, the health system, CMS, TJC, and other regulatory bodies are collected, submitted, analyzed, and improved throughout the entirety of SAHS. In conjunction with other responsible leaders, develops, implements, and evaluates an annual Quality Assurance and Performance Improvement plan. Provides expert guidance to performance improvement teams in the areas of performance improvement processes and methodology, data analysis, regulatory interpretation, and facilitation.

Provides current, accurate data and analysis of data to appropriate stakeholders. Assists with local hospital implementation and evaluation of a continuous regulatory readiness plan including ongoing monitoring through audits and tracers, education, process improvement, policy development/revision and other methods. Resource for standards/regulation interpretation and implementation. Assures system-wide compliance with required data submission. Represents the SAHS Performance Improvement program at Trinity-level and community forums, as appropriate. Participates as a member or consultant in organizational decision making, including the development of policies and procedures.

Responsible for leading the identification of opportunities for performance improvement and prioritizing recommendations to Senior Leaders within the system. Collaborates with local and system leaders to initiate performance improvement efforts that correlate with departments/units with the highest opportunity to improve based on System Office and SAHS priority metrics. Standardizes policies, procedures, practices, products/equipment, monitoring, and communication across the system.

Demonstrates ability to work effectively with professional and supportive personnel throughout the system to promote a culture of safety. Strong influencing, collaboration and partnering skills with the credibility to lead change and develop productive working partnerships with leaders, managers and staff. A true believer in nurturing teamwork, developing others through mentoring and coaching. Strong communication, organizational, negotiation and leadership skills with the ability to facilitate communications between diverse groups and effectively influence and present advisory consultation.

Demonstrates ability to work effectively with providers, administration, and other colleagues to promote increases in positive patient outcomes and reduction of errors. Working knowledge of hospital information systems. Knowledge of healthcare organizational processes. Strong computer skills with an emphasis on MS Word, Excel, and PowerPoint. Competency in each of the following functional areas: Interpretation of basic inferential statistics and statistical process charting. Database management. Adult education-teaching individuals/groups using adult learning principles. Group facilitation and leadership. Analysis of relevant aspect of collected data.

**Our Commitment to Diversity and Inclusion**

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran