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

• Director of Performance Improvement Operations will oversee the identification, prioritization, quantification, project management, and success of designated quality assurance and improvement initiatives.

• 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 DNV 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 quality care is 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.

• Ensures that all quality and regulatory action plans are created and monitored for proper corrective action.

• Responsible for the appropriate dissemination of Quality and Performance Improvement 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 education for new employees and in continuing education for all employees.

• Facilitates the internal medicine and family practice committee. Coordinates the mortality and peer review information for the different physician committees.

• 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.
• Ensures that Quality care is provided and is monitored.

Education
Bachelor's Degree required, Masters Degree preferred.

Minimum Work Experience
• Minimum of two (2) years of experience in a managerial position in a clinical setting. Also, Performance Improvement and DNV and Regulatory standards knowledge required.

Required Skills, Knowledge, and Abilities
• 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.