We are so glad you are interested in joining Sutter Health!
Organization:
CPMC-California Pacific Med Center
Position Overview:
This position replacing r-130399 and now has PD added to job code
Job Description:
Performance Improvement.
Serves as primary support to clinical and operational leadership in monitoring and evaluating processes for outcomes management, performance improvement and peer review.
Facilitates improvement activities for specific areas of responsibility.
Promotes collaboration, decision making, and problem solving through effective interactions or facilitations with members of the ambulatory or hospital organization. Oversees and coordinates process improvement activities related to the organization- wide outcome measures defined through established quality and safety strategic goals which optimize clinical care and reduce waste and rework.
Collects and retrieves data, designs, and uses spreadsheets and databases for clinical and administrative decision making, and analyzes data for relationships to outcomes.
Conducts basic and advanced analyses of performance on clinical processes and outcomes. Reviews, evaluates, interprets, and develops reports, and provides end-user assistance, involving analysis, identification of problem needs, designing solutions, and identifying required system adaptations with a high level of independence.
Maintains and disseminates information on successful interventions and programs proven to be effective and evidence-based practices.
Acts as a departmental representative in meetings involving ambulatory or hospital policy issues surrounding performance improvement, decision support, and utilization of ambulatory or hospital resources.
Prepares and presents educational programs on performance improvement, evidence-based practice, or ongoing quality initiatives to physicians and clinical staff.
Assists in the development of an organization wide performance improvement plan (supplementary to the corporate performance improvement requirements) which integrates the medical staff / medical group structure and activities, and in the development of long-term strategies and methodologies for evaluation of processes and outcomes across the continuum of care including measurement, analysis, and reporting of data used in achieving goals identified in the strategic plan.
Using strong performance improvement skills including ability to manage a project from conception to completion, facilitate meetings, provide timely accurate data/information, and present information in a clear, concise manner. Maintains knowledge of all applicable standards from accreditation and regulatory bodies.
Regulatory Compliance.
Provides education on standard changes and compliance outcomes. Organizes all on-site surveys managing the survey activation plan. Works with affiliate and system content experts to develop and implement processes to assure regulatory compliance with complex requirements.
Responsible for reviewing internally / externally reported measure performance including collaboration with the process owners to develop action plans to improve performance, identify need for interdisciplinary process improvement, and follow- up with physicians.
Using in-depth knowledge of healthcare regulations, standards and internal / external measures, identifies opportunities for improvement, and creates relevant reports and action plans.
Public Quality Reports.
Proactively manages performance on public quality reports. Serves as a resource and expert on public quality reporting organizations. Responsible for ensuring compliance with internal and external regulatory requirements. Completes system under the supervision of the Quality and Patient Safety Manager/Director and approval of leadership.
Directly supports in the planning and implementation of a systematic program for improving performance on public quality reports. Responsive to health plan, regulatory and other expectations for clinical quality outcomes.
Special Reports.
Completes special projects and/or additional tasks specifically, participation in regional or corporate projects associated with clinical and patient safety performance improvement outcomes or responses to external inquiries.
Assumes special assignments as delegated. Performance to be evaluated in terms of accuracy, completion due date, adherence to instructions and cooperation.
Train new staff.
WHEN SUPPORTING AN MBSAQIP BARIATRIC PROGRAM
Conducting chart abstraction 100% of bariatric procedures performed as mandated by the Metabolic and Bariatric Surgery Quality Improvement (MBSAQIP) standard by using patient-level health information from electronic medical records.
Coordinates data collection and maintains database systems for effective quality improvement.
Work closely with the center and clinicians to ensure that appropriate short-term and long-term data elements are available in the medical records.
Satisfactory completion of online initial training, as well as ongoing maintenance of certification by completion of a yearly certification exam, as well as compliance with MBSAQIP data integrity audits when necessary.
Reports bariatric data to relevant groups and assist in the production and dissemination of standard reports and outcomes as directed by the director or the coordinator.
EDUCATION:
Equivalent experience will be accepted in lieu of the required degree or diploma.
Bachelor's in Management, public health, nursing, business administration, organizational leadership, or related field
DEPARTMENT REQUIRED EDUCATION
Department, MBSAQIP Accredited Center (Bariatrics): Bachelor's in Management, public health, nursing, business administration, organizational leadership, or related field
DEPARTMENT REQUIRED CERTIFICATION & LICENSURE
Department, MBSAQIP Accredited Center (Bariatrics): Certification as the MBSCR (Metabolic and Bariatric Surgical Clinical Reviewer) or successful training and pass the MBSCR exam within 60 days of hire
Department, MBSAQIP Accredited Center (Bariatrics): Registered healthcare professional (BSN, Public Health Nurse, Social Worker, Health Educator/Health Education Specialist, Health Services/Healthcare Administrator. Clinical Laboratory Technologist, Diagnostic Medical Sonographer, Medical Dosimetrist, Biomedical Engineer/Bioengineer, Bioinformatics/Biostatistician Specialist, Blood Bank Technologist, Cytotechnologist, Radiation Therapist, Forensic Science Technician, or Registered Health Information Technician)
TYPICAL EXPERIENCE:
5 years recent relevant experience.
SKILLS AND KNOWLEDGE:
Demonstrated proficiency in Microsoft Office Suite, including Word, Power Point, and Excel. Ability to format tables, retrieve data via queries, and create presentations via PowerPoint.
Ability to navigate an electronic health record.
In-depth Knowledge of accreditation and regulatory standards
Must demonstrate written/verbal interpersonal communication and problem solving skills. Ability to communicate effectively with a wide variety of personalities and departments, including medical staff members.
Ability to manage own time and schedule own tasks. Must have initiative to work effectively without constant supervision and direction. Experience managing and prioritizing multiple projects/duties.
The ability to manage performance improvement projects from conception to completion. This position requires analytic, problem resolution, persuasion and negotiation skills.
Possess organizational skills.
The ability to plan, organize, set and execute objectives.
The ability to organize and prioritize multiple projects.
Demonstrated initiative and ability to work under minimal supervision.
Evidence of ability to apply teaching and learning principles.
Ability to work with and motive a diverse groups of individuals working together on an initiative.
Interpersonal skills to tactfully direct the efforts of diverse groups of health professionals towards performance improvement and risk reduction activities.
PHYSICAL ACTIVITIES AND REQUIREMENTS:
See required physical demands, mental components, visual activities & working conditions at the following link: Job Requirements
Job Shift:
Days
Schedule:
Per Diem/Casual
Shift Hours:
8
Days of the Week:
Variable
Weekend Requirements:
None
Benefits:
No
Unions:
No
Position Status:
Non-Exempt
Weekly Hours:
0
Employee Status:
Per Diem/Casual
Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.
Pay Range is $52.44 to $78.66 / hour
The compensation range may vary based on the geographic location where the position is filled. Total compensation considers multiple factors, including, but not limited to a candidate’s experience, education, skills, licensure, certifications, departmental equity, training, and organizational needs. Base pay is only one component of Sutter Health’s comprehensive total rewards program. Eligible positions also include a comprehensive benefits package.
