The Director of Process and Performance provides a planned, systematic, organization-wide approach to designing, measuring, assessing and improving its performance.  Coordinates with hospital administration, department directors, and managers to assure compliance.

• 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.
• 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.
• 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.