Performance Improvement Manager Job
Full Job Title: Performance Improvement Manager
Job Number: 17008811
Facility: SSM Health Saint Louis University Hospital
Location: St. Louis, MO
Schedule: Full Time
SSM Health Saint Louis University Hospital
Performance Improvement Manager, Full Time
- Manages and monitors the quality, safety, and infection prevention/control activities of the hospital to maintain compliance with evidence based initiatives and regulatory agencies.
- Manages the infection control and safety program with the responsibility to create, administer program policies and coordinate all infection prevention/control and safety activities within the hospital. Serve as a consultant to staff, managers, residents and physicians regarding quality, safe and cost effective medicine in the hospital setting.
- Manages infection control, quality and patient safety activities to ensure compliance with regulatory agencies as well as company wide initiatives.
- Integrates surveillance findings and develops formal plans for improvement of practice and patient outcomes in various healthcare settings.
- Uses appropriate surveillance processes to identify nosocomial and community acquired infections and environmental hazards. Monitors effectiveness of prevention and control strategies that are consistent with the organization's goals and objectives.
- Provides expertise regarding infections, communicable diseases and isolation procedures in planning for delivery of care to patients, acts as resource to staff regarding appropriate isolation and care to reduce risk of infection and patient harm.
- Reviews, analyzes and implements regulations, standards, and/or guidelines of applicable governmental agencies and professional organizations including communicating changes, maintaining documentation books, and data analysis
- Coordinates completions of applicable hospital plans, hospital evaluations, and manuals as well as assisting departments with reviewing/revising departmental policies and procedures.
- Develops and implements policies and procedures based on current best practices. Analyzes and applies pertinent information from current scientific literature and publications.
- Ensures that findings, recommendations, and policies of the program are disseminated to appropriate groups or individuals.
- Evaluates methods of decontamination and sterilization and develops appropriate guidelines in accordance with established policies and various regulatory agencies.
- Actively participates in the evaluation and implementation of current and new equipment and supplies in all matters related to infection control and patient safety utilizing cost effective principles. Closely observes and monitors hospital environment to identify and eliminate infection and patient safety hazards including care of patient at bedside, cleaning techniques used between patients, disposal of contaminated supplies, sharps disposal and hand washing techniques.
- Actively participates in the planning for construction and renovation projects to meet regulatory requirements and ensure compliance with ICRA permit process.
- Functions as an integral part of performance improvement initiatives to promote positive patient and clinical staff outcomes.
- Actively participates with interdisciplinary groups in establishing appropriate criteria for quality improvement programs which relate to infection control and patient safety issues.
- Identifies opportunities for improvement based on observations, process and outcome indicators, and other findings.
- Collects quantitative, comparative data on organizational performance including all indicators identified for infection control and patient safety. Develops, analyze and distribute finding and reports to Administration, Medical Executive Committee, Governing Board and Medical Staff Committees as appropriate.
- Acts as an agent of change and participates in the change process
- Directs the organization's infection prevention and control improvement activities
- Participates in the organization's multidisciplinary improvement strategies
- Accurately investigates potential infection and patient safety hazards and deviations from hospital infection rates, by conducting epidemiological studies for clusters of infection and coordinate isolation rounds to assess proper isolation procedures.
- Utilizes established measurement tools and techniques, e.g., outbreak investigation, root cause analysis, brainstorming, and others.
- Contributes epidemiologic skills to improvement processes
- Collaborates with various agencies charged with responsibility for tracking and decreasing the spread of infectious diseases including disaster preparedness.
- Serves as consultant to departments and disciplines with planning, measuring, assessing and improving processes and outcomes.
- Promotes team-building (team facilitation) efforts as they relate to Performance Improvement Initiatives.
- Maintains ongoing coordination between the various components of the Risk Management and Performance Improvement Department to assure timely and appropriate referrals and follow-up.
- Facilitates Performance Improvement team efforts to explore alternative strategies for improving processes.
- Serves as an educator and educational resource for healthcare providers, ancillary staff, physicians, patients, families and general public.
- Serves as an administrative designee for Medical Staff committees as assigned.
- Coordinates Comprehensive Unit Safety Based Programs.
- Promotes service standards and facilitates services recovery when necessary.
- Facilitates interdepartmental reviews.
- Collaborates with customer relations department to assure appropriate information is communicated and opportunities to improve are identified.
- Demonstrates ability to relate to coworkers in a professional and respectful manner, in order to assure and promote a culture of safety.
- Experienced healthcare professional with a health sciences background
- An epidemiologist, medical technologist (MT), or registered nurse (RN)
- Has knowledge and experience in patient care practices, microbiology, aseptic technique, disinfection/sterilization, adult education, infectious diseases, communication, program administration, and epidemiology
- Must have minimum of Bachelors degree in health care related field, Biology, Medical Technology, Nursing or Public Health. Must have working knowledge of JCAHO and Missouri Department of Health Standards. Education and experience in statistical concepts, data management, variance tracking and analysis.
- Becomes certified in infection prevention and control when eligible through the Certification Board of Infection Control and Epidemiology, and maintains certification.
- Minimum of 2-3 years of clinical experience. Minimum 2 years experience in quality improvement, safety or infection control preferred.
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