The Director of Process and Performance provides a planned, systematic, organization-wide approach to designing, measuring, assessing and improving its performance. Directs Risk Management activities and coordinates with hospital administration, department directors, and managers to assure compliance with JCAHO, HCFA, State Licensure Board and other governmental or accredited agencies.

Directs the ongoing operations of the Process Improvement program to integrate the plan into the primary objectives of the organization, under the guidance of the Administrator and the Performance Improvement Steering Committee.

Ensures compliance with JCAHO and related standards, HCFA, State and Federal Licensure Board, and other accrediting agency requirements. Requests assistance as needed with hospital administration, hospital directors and managers.

Assures that the hospital departments have a planned and systematic process for monitoring, evaluating and improving the quality and appropriateness of care provided to the patients.

Assures that there is a written plan for Process Improvement Program that describes the objectives, organization, scope and mechanisms for overseeing the effectiveness of monitoring, evaluations, and problem solving activities.

Reviews consultant pre-survey reports and all previous accreditation reports, develops and manages action plan to address findings. Assist in preparation of contingency responses and focus surveys.

Formulates and implements the hospital’s risk management program, oversees the development and maintenance of facility wide risk management policies and procedures, and ensures that the organization is in compliance with all system and regulatory agencies in regards to risk management.

Responsible for the appropriate dissemination of risk management information including trending reports to all levels of the organization as appropriate, i.e. medical staff, hospital committees, department managers and governing board.

Participates in performance improvement/risk management education for new employees and in continuing education for all employees.

Facilitates hospital performance improvement teams, ensuring team completeness in a timely manner. Collects all team report cards and prepares monthly and quarterly reports to be sent to Performance Improvement Steering Committee.

Ensures that all departments understand the P.I. model and utilize it on a daily basis.

Directs the loss prevention and risk management function.

Performs other related duties as assigned.

Bachelor’s Degree required, Masters Degree preferred. Minimum of two (2) years experience in a managerial position in a clinical setting. Also, Performance Improvement and JCAHO and Regulatory standards knowledge required.

Demonstrated ability to analyze data, report and manage patient care information typically obtained through previous experience. Demonstrated written, verbal communication and presentation skills required. Excellent computer skills including both word processing and spreadsheet knowledge required.