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Performance Improvemnt Advisor

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POST DATE 9/10/2016
END DATE 1/25/2017

Hackensack University Medical Center Hackensack, NJ

Hackensack University Medical Center
Job Classification
Full Time
Company Ref #
Hackensack, NJ
Mid-Career (2 - 15 years)
Job Type
Bachelors Degree
AJE Ref #


The Performance Improvement Advisor is a part of a self directed workgroup with expertise in quality improvement. The Improvement Advisor provides professional support related to the design and the implementation of performance improvement plans across the organization. The Improvement advisor guides and advises at all levels including Senior Leaders, Chairman and other organizational leadership regarding; process design, principles of reliability and bundle science, evaluation of operational and clinical outcomes and facilitates achievement of excellent level of clinical outcomes through publicly reported data. The advisor, in conjunction with organizational leadership, develops and facilitates effective execution of the HUMC Performance Improvement Plan. In collaboration with Directors, Clinical Chairs, Senior Leaders and other professionals, ensures deployment of a for a systematic, coordinated measurement and evaluation process to improve care, through put, service delivery and patient outcome. Participates in the development and successful deployment of the Service Line and Departmental Performance Improvement plans based on organizational priorities that support and align with the Medical Center's strategic plan, mission, vision and goals. The Improvement Advisor functions as a resource to improvement teams, service line teams and all organizational departments. 1. Oversees the development, deployment, evaluation of performance design and improvement cycles. 2. Demonstrates use of appropriate methodologies and relevant tools to opportunities to evidence rapid cycle improvement (i.e. PDSA, FMEA, reliability theory, bundle science, RCA, Process Flows, Affinity diagrams). 3. Utilizes appropriate analytical tools and statistical process control to evaluate results. 4. Ensures that there is effective analysis of performance data with comparison over time and comparisons to internal and external benchmarks to identify improvement opportunities. 5. Facilitates analysis of data through use of specific tools and methods. Assists teams with understanding and interpreting their data. Performs 'just in time training as necessary' for teams and Service Lines as needed. 6. Ensures trend analysis is performed and appropriate response to unfavorable trends are developed and deployed. 7. In conjunction with clinical leaders, performs focused studies on diagnosis, procedures and various performance measures based on pre-determined criteria. 8. Demonstrates expertise in Rapid Cycle Improvement methodology, Bundle and Reliability Science. 9. Assures appropriate membership and participation of al work teams. 10. Utilizes refined facilitation skills to ensure maximum participation of individuals and teams. 11. Uses CQI tools and principles in all team related work. 12. Ensure plans and designs are consistent with internal and external expectations for accreditation, regulatory compliance and public reporting. 13. Ensures that all meetings evolve to actionable work to reduce cycles of improvement. 14. Facilitates sharing and learning horizontally across the organization through participation in improvement day activities, presentations to teams, medical board committees, and assisting team members in knowledge synthesis. 15. Function as the key contact/team member for multi-hospital collaborative work including; team conference calls, posting of data, analysis of data and weekly cycles of change with reporting storyboard development. 16. Represent HUMC at local, regional and national meetings demonstrating and articulating the HUMC model for improvement and key results. 17. Supports Patient Safety through active participation in the identification of actual or potential patient safety issues. Oversees the development of appropriate risk reduction strategies, use of tools and methods that support patient safety. 18. Works effectively with the Medical Staff to facilitate development and implementation of practice guidelines, resulting in the ability to profile physician activities, determine appropriate practice indicators in all clinical areas and produce effective outcomes. 19. Communicates problems or trends identified to appropriate committees, Medical Staff, Administrative staff and/or management staff. 20. Works collaboratively with Risk Management in developing performance improvement activity. 21. Educates the appropriate personnel in the techniques of Performance Improvement through various modalities (didactic, Just in Time training). 22. Organizes and facilitates regularly scheduled training sessions with the managers, team leaders and staff as needed to educate and implement quality improvement principles and goals as a strategy. 23. Teaches the concepts of improvement - Model for Improvement, Accelerating Improvement, Measurement for Improvement, Local Spread, Large-scale Spread and Sustaining Improvement at learning sessions and conference calls. 24. Provides coaching on improvement issues to participating teams at learning sessions, conference calls, list serve and emails necessary to achieve project goals. 25. Ensures design and improvement plans are fully compliance of JCAHO, NJDOH, and Federal Standards. 26. Communicates and educates compliance of JCAHO and regulatory standards. 27. Guides departments into developing strategies that meet requirements. 28. Assists with the design of materials to demonstrate compliance with standards. 29. Maintains current knowledge and expertise with external demands. 30. Represents Medical Center to accrediting bodies to facilitate and coordinate accreditation processes, to ensure satisfactory completion, and improve compliance. 31. Represents the Medical Center with other quality improvement organizations, health agencies, groups, government agencies and third party payers at the local, regional and national level. Acts as a liaison to provider organizations to develop improvement strategies and determining strategies for success. 32. Ensures a systematic process for and supervises the investigation of incidents, sentinel events, near misses and ensures that a thorough root cause analysis is conducted when indicated. Ensures that there is an effective system in place for the identification, investigation and reporting of NJDOH required Patient Safety events. Monitors trends and identifies opportunities for improvement. 33. Provides oversight and is responsible for an effective peer review process and maintenance of physician performance profiles. Provides trends analysis to respective audiences. 34. Adheres to the standards identified in the Medical Center's Organizational Competencies. 35. Maintains professional growth and development through seminars, workshops and professional facilitations to maintain and extend expertise. Working Conditions: Lifts a minimum of 10 lbs., pushes and pulls a minimum of 25 lbs. and stands a minimum of 1 hour a day. Education, Knowledge, Skills and Abilities Required: 1. Excellent written and oral communication skills. 2. Strong presentation and facilitation skills. 3. 5 years of clinical experience in an acute care hospital. 4. Bachelor of Science in Nursing or Health Care Administration. 5. Experience in the use of computer applications and software. Education, Knowledge, Skills and Abilities Preferred: 1. Master Degree in Nursing, Business or Health Care Administration. 2. Understanding of JCAHO and Regulatory Standards. 3. Previous Management experience. 4. Recent 3-5 years experience in Quality or Performance Improvement measurement and statistics. Licenses and Certifications Required: 1. NJ State Professional Registered Nurse License. Licenses and Certifications Preferred:

We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.