JOB SUMMARY

The Manager, Performance Improvement has oversight and responsibility for the internal audit and corrective action request (CAR) system. Coordinates the audit schedule, following up on outstanding corrective actions and reporting on the audit outcomes through the quality management system. This position requires a deep understanding of process improvement methodologies, lean six sigma and ISO standards as well as an ability to effectively communicate and educate these methodologies to peers. A key aspect of this role is the ability to analyze work processes and data effectively, producing reports and visualizations that highlight pattern and trends and identifies areas for improvement.
This position will play a crucial role in the coordination, organization and designation of Performance Improvement Teams. Assists in identifying performance improvement initiatives through common cause and special causes analysis of targeted high risk, and high volume healthcare processes. In collaboration with the Quality Management Department leadership team, supports the organizational priority of high reliability and the peer review process.

• Responsible for the oversight of the Office of Performance Improvement.
• Coordinates, directs and manages the processes and policies involving Internal Audits and CAR(s) ensuring they meet the ISO standards.
• Maintains all Corrective Action Requests (CARs) and Concerns from Internal Audits, Root Cause Analysis, and External Surveys by regulatory agencies etc. and various other sources as per the ISO 9000:2015 Standards.
• Generates Corrective Action Requests (CARs) for all external regulatory agency plans of corrections (Department of Health, DNV Healthcare etc.). Monitors the CARs database for responses and appropriateness for closure of these regulatory requests.
• Identifies performance improvement targets through systematic data analysis, trend identification and pattern recognition.
• Coordinates and facilitates performance improvement teams using methodologies such as Lean, Six Sigma, or Plan-Do-Study-Act (PDSA), DMAIC to ensure sustainability of improvement strategies.
• Conducts and participates in Root Cause Analysis, Apparent or Common Cause Analysis and Failure Mode Effects Analysis to assist with the identification of processes/systems requiring improvement.
• Assists in the identification, planning and execution of improvement projects throughout the organization.
• Participates in the external regulatory agency survey process, identifying needed Corrective Action Requests (CARs), Internal Audits, and/or processes/systems improvements as required.
• Assists with data analysis, summarization and visualization of Quality Events, Patient Safety Events and Patient Relation Events to identify patterns and trends proactively and assess for performance improvement opportunities.
• Shares insights derived from analysis and summarization with appropriate leadership levels, both directly and through the quality management system.
• In conjunction with the Quality Management Department leadership team, designs, implements and facilitates programs or activities intended to enhance performance in clinical quality, patient safety, and regulatory compliance throughout the hospital.
• Actively participates on teams and committees related to peer review and process improvement at MVHS as required.
• Maintains current knowledge of the Medical Staff Bylaws and Rules and Regulations.
• Proactively shares knowledge of current performance improvement methodologies and practices. Serve as a resource and role model to individuals and teams regarding to quality, safety and compliance activities and best practices.
• In partnership with leadership and Human Resources, makes decisions or recommendations related to performance management, hiring, transfers, corrective actions, terminations, etc. Resolves staff issues or grievances in a fair, timely and consistent manner, also in partnership with HR.
• Provides information to the Quality & Patient Safety Operations Committee and Quality & Patient Safety Oversight Committee of the Board for review and action as needed, including summarization of performance improvement activities.
• Assists in the development and revision of policies and procedures that support performance improvement and operational excellence.
• Performs related duties as required.