performance improvement specialist

JOB SUMMARY: Under the direction of the Deputy Director of Healthcare Quality Specialist will collect, organize and facilitate PI activities, data, meeting documentation including minutes and will work to develop and perform performance improvement initiatives at Franklin Primary Health Center, Inc. in accordance with Joint Commission, NCQA, center administration and medical staff goals and the approved Performance Improvement (PI) plan. The Performance Improvement (PI) Specialist supports Franklin Primary Health Center's quality, safety, accreditation, and workforce competency goals by integrating performance improvement activities with staff development and training oversight Monitors unusual occurrences, report follow-up procedures, and report monthly and year-to-date comparisons.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

1. Coordinates, schedules and performs follow up for Franklin Primary Health Center's PI Committee, Safety Committee and other essential committees as assigned and helps to develop agenda items, minutes, policies, protocols, and changes for committee.

2. Works cooperatively with Health Information and clinical staff during course of audits. Collects information from patient charts to complete audits as required by federal guidelines and to measure quality improvement in accordance with health care plan.

3. Aggregate, analyze and disseminate data.

4. Collects, organizes and prepares reports on an ongoing basis, staff and patient surveys/comments throughout the organization

5. Prepares reports from compiled information collected in audits; helps develop audit tools and reporting forms.

6. Keeps the Deputy Director of Healthcare Quality and/or Director of Healthcare Quality informed of essential PI activities such as but not limited to: studies in process and progress thereof, committee agenda items; discusses problems and completion of audit procedures.

7. Assists with the monitoring and gathering of information and documentation about unusual occurrences (incident reporting) of unusual occurrences; prepares action-taken reports, assists with the identification of problems through statistical information, monitoring, and reporting results of action taken to reduce risks to patients.

8. Provides approved quality and PI information to center employees and visitors as directed

9. Maintains confidentiality of information discovered through the quality assurance program. Conclusive proof of violation of confidentiality will be considered grounds for possible termination.

10. Responsible for achieving a satisfactory work environment between other departments performing quality-assurance studies, and assisting when necessary with the accumulation, display, routing and dissemination of the information to appropriate committees, physicians, and departments

11. Completes assigned tasks in infection control, Environment of Care, Joint Commission and OSHA process. This may include compliance audits, random unannounced surveys and completion of tracers as assigned.

12. Participates in the company's emergency management planning and implementation and represents Franklin in community meetings and holds an internal leadership role with the Franklin Emergency Response Plan.

13. Communicates professionally verbally and in writing with staff, providers, patients and external customers at all times.

14. Maintains a high degree of organization for storage and retrieval as needed of pertinent PI data and information.

ADDITIONAL RESPONSIBILITIES:

1. Assists as needed with OSHA and safety plans for Franklin Primary.

2. Coordinates OSHA and safety training (annual, updates, and orientation) with PI staff.

3. Keeps Center current with compliance issues, changes and progression of implemented initiatives.

4. To perform other assigned duties as assigned by the Deputy Director of Healthcare Quality/Director of Healthcare Quality, COO or CMO.

5. Serve as an active PI team member specifically focused on identifying training-related performance gaps.

6. Assign training curricula by employee group

7. Monitor and report training compliance

8. Train staff and managers on LMS usage

9. Coordinate with HR for onboarding and offboarding

10. Translate audit findings, incidents, and PI outcomes into targeted education plans.

11. Develop, coordinate, and evaluate staff development and professional education programs.

12. Design training curricula, learning objectives, materials, and evaluation tools.

13. Schedule and facilitate training sessions (live, virtual, blended learning).

14. Evaluate training effectiveness and adjust programs based on outcomes and PI data.

The preceding examples are representative of the assignments performed by this position and are not intended to be all-inclusive.

CUSTOMER SATISFACTION: Must provide the very best customer satisfaction to patients, visitors, and co-worker at all time in a professional and courteous manner. Provide assistance in resolving customers' problems. Coordinate efforts and interfaces with other departments to resolve problems. Actively protects customer confidentiality. Actively keeps environment clean and safe with a professional and welcoming image. Always treats customers as welcome guests and provide a warm and sincere greeting. Consistently presents a professional appearance in dress and grooming by adherence to dress code policy. Effectively and regularly demonstrates the values of the organization. Effectively involves customers in decisions that affect them. Follow through in a timely manner of commitments made to customers. Take ownership of your attitude toward Service Excellence .

PERFORMANCE STANDARDS: Performance will be evaluated by the Deputy Director of Healthcare Quality or Director of Healthcare Quality annually wherein a satisfactory overall rating is considered a minimum acceptable level of performance.

HEALTH AND SAFETY:

1. Must adhere to safety policies and procedures.

2. Must receive Safety and Hazardous Communication training annually.

3. Must exercise universal precautions and comply with safety standards and procedures.

4. Knowledgeable of Joint Commission, NCQA, OSHA and CLIA requirements to assure compliance.

PRIVACY RULE COMPLIANCE REQUIREMENTS:

1. Adheres to Health Insurance Portability and Accountability Act (HIPAA Privacy Rule) policies and procedures.

2. Must successfully complete Privacy Rule compliance training annually or as revisions are made to the P&P's.

3. Must comply with Privacy Rule guidelines by learning to protect FPHC patient's medical privacy.

4. Must comply with Privacy Rule guidelines by appropriately maintaining our patient information in compliance with national standards.

5. Must comply with Privacy Rule guidelines by providing appropriate security of FPHC patient records.

QUALIFICATION:

EDUCATION AND EXPERIENCE: Bachelor's degree in medical or related field preferred, one-year report formulation experience preferred.

Proficiency with a word processing program and knowledge of medical terminology required.

Experience in performance improvement, quality management, staff education, or regulatory compliance preferred

KNOWLEDGE, SKILLS AND ABILITIES:Ability to read, analyzes, and interprets general business periodicals, professional journal, technical procedures, or governmental regulations. Ability to write reports business correspondence and procedure manual. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the public. Knowledge of accepted medical records practices, including medical ethics, classification, and organization. Knowledge of accreditation standards applicable to the medical staff, PI committee activities, and medical records department.

• Knowledge of Joint Commission, NCQA, HRSA, OSHA, and CLIA requirements
• Strong analytical, organizational, and problem-solving skills
• Ability to design and evaluate training programs for adult learners
• Proficiency in data analysis, reporting, and learning management systems
• Excellent written and verbal communication skills
• Ability to work independently and manage multiple priorities

Must possess a strong verbal, written, and analytical skills and the ability to work independently. Must be highly organized.

CERTIFICATIONS, LICENSES AND REGISTRATIONS:

PHYSICAL/MENTAL DEMANDS:

1. Work is varied in nature and is performed with frequent interruptions. Work requires close attention to detail and accuracy. Occasional mental stress is involved in completing PI activities with regards to physicians and ancillary departments and interrelationships.

2. Work requires sitting, standing, stooping, bending, driving and a considerable amount of walking, moving and examining objects at high and low reach, and reading.

Job Type: Full-time

Pay: $45, $60,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Employee assistance program
• Health insurance
• Life insurance
• Paid time off
• Parental leave
• Retirement plan

Experience:

• OSHA and safety training: 1 year (Preferred)
• healthcare: 1 year (Preferred)

Work Location: In person