PI Coordinator

Mission Community Hospital-posted 3 months ago
Los Angeles, CA
251-500 employees
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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.

  • Greets/acknowledges customers warmly, with a smile, and immediately when they enter department/unit/area.
  • Asks how the customer may be helped with interest and concern.
  • Listens attentively, does not interrupt.
  • Accepts ownership and takes action to resolve customer needs and/or concerns.
  • Is attentive and responsive to the expectations of physicians and co-workers.
  • Accepts constructive criticism and modifies actions accordingly.
  • Is generous in acknowledging a job well done.
  • Uses words and behaviors that express consideration, concern and respect.
  • Facilitates and holds staff accountable for meeting department customer service standards in the performance of duties.
  • Utilizes telephone skills effectively as outlined in the Star Service Program.
  • Keeps all private information about staff or patients confidential.
  • Identifies customers and their service requirements.
  • Meets or exceeds customer service improvement targets as demonstrated by dashboards, etc.
  • Participates in marketing activities of the Hospital including but not limited to committees/task forces, speaking engagements, conducting tours, Hospital sponsored health fairs.
  • Contributes to marketing materials such as brochures, newsletters, teaching materials.
  • Participates in staff recognition activities in ways that reward behaviors reflecting positively on Mission Community Hospital.
  • Engages in interdepartmental / multi-department/house-wide process improvement forums/taskforce/committees.
  • Offers and implements solutions to challenges/problems.
  • Assist with the development-related activities including fund raising programs and activities.
  • Monitors the marketplace and recommends new and creative business opportunities.
  • Analyzes targeted existing services and product lines for cost/benefit and develops appropriate strategies to improve growth where applicable.
  • Attends/participates in activities that contribute to professional growth and development.
  • Responsible for coordinating, facilitating, and reporting hospital-wide PI activities/initiatives including inpatient and outpatient Core Measure data abstraction.
  • Responsible for assisting with coordinating and facilitating hospital-wide accreditation and regulatory agency survey preparedness and readiness.
  • Implement performance improvement processes that lead to a positive and measurable patient care and service impact.
  • 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.
  • Reviews QualityNet website on a regular basis to keep abreast of new changes and updates.
  • 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.
  • Searches out best performance and quality improvement practices, making department leaders aware of them, and suggesting areas where they could be implemented.
  • Assist the Director of PI in coordinating the Quality Council.
  • Develops and analyzes performance improvement data for the council, designs and implements the necessary Quality Council processes and systems.
  • 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.
  • 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.
  • Assist the Director of PI in coordinating and facilitating peer review activities as needed.
  • Assures policy and procedure standards comply with local, state, and federal law and regulatory requirements.
  • Recommends changes in the administrative policies that conform to accreditation standards and California/Federal regulations.
  • Assist with developing and implementing policies and procedures that support the provision of services.
  • Submits accurate and timely status reports to the Director of PI and/or hospital committees as required.
  • 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.
  • Identifies and reports national/regional benchmarks or outcomes excellence targets that assist in identifying/supporting performance improvement opportunities.
  • Uses a disciplined process improvement method (the FOCUS-PDCA methodology) and performance improvement tools.
  • Assists the Director of PI in assuring that process improvement teams and committees develop strategies to improve patient care outcomes.
  • 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.
  • 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.
  • Possess and maintains a working knowledge of Joint Commission standards, State of California laws and statutes, CMS regulations, policies and procedures, and community standards.
  • Evaluates, monitors, and sustains compliance with accreditation and regulatory bodies.
  • Coordinates MCH's continuous readiness for the Joint Commission, DHS and CMS surveys in collaboration with the Performance Improvement.
  • Performs other duties as related or assigned.
  • Current California RN license required.
  • Minimum of BSN degree preferred.
  • Minimum two years acute hospital nursing experience required.
  • Two years performance improvement/outcomes management experience in acute care setting preferred.
  • 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.
  • Certified Professional in Healthcare Quality (CPHQ) preferred.
  • Excellent English written/verbal communication skills.
  • Computer skilled with experience using Microsoft Office software at an intermediate level.
  • Intermediate to advanced level Microsoft Excel database and statistical analysis skills required.
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