TITLE: Ancillary/Outpatient Performance Improvement Coordinator

REPORTING RELATIONSHIPS: Reports directly to Executive Director of Quality/Risk Management

QUALIFICATION: 

1. Education:  Minimum of an associate degree in a relevant clinical field.  Depending on the field, if licensure is required for practice, it is required for the position 

2.   Training and Experience:  Three years’ experience in a hospital/outpatient setting.   Previous experience with medical record review, statistical, analytic, and decision support is desirable.  Fluency with software/applications desirable including, but not limited to, all Microsoft Office applications. 

3. Job Knowledge:   Broad knowledge of quality and safety topics relevant to the provision of care, treatment and services.  Basic knowledge of performance improvement in healthcare setting, including aggregating relevant data into meaningful reports for tracking performance and decision making. 

4. Skills: The successful candidate should possess strong organization, data abstraction and research skills. The associate will be expected to demonstrate communication and interpersonal skills that support the organization’s customer service strategy.

  4. Safety Sensitive:   NO

In the interest of protecting the health and safety of all patients, associates, and guests, Unity Health has classified some positions as “safety sensitive.”  A “safety sensitive” position is any job position in which impaired performance could result in harm to the health and/or safety of self or others. Any associate that is actively engaged in the use of medical marijuana, even if in possession of a valid medical marijuana card, will be excluded from employment in a “safety sensitive” position. 

DESCRIPTION: 

The Ancillary Performance Improvement Coordinator is expected to lead Unity Health’s PI initiative specific to the ancillary/outpatient setting.  The associate will work with administrative and departmental leadership to monitor the quality of care being provided, identify opportunities for improvement, and lead performance improvement activities to achieve excellence. The associate is responsible for preparing statistical reports, meeting minutes, orientation and in-service related materials as well as leading and facilitating PI activities.  As relevant to the needs of the departments, associate may be involved in regulatory compliance activities as well as policy, procedure, protocol and education development.

Job Hazards: Minimal danger of contracting disease if proper technique is followed: accidental hazards are almost nil if policies are followed and safety precautions observed. 

Category III: Tasks that involved no exposure to blood, body fluids, or tissues. Person who perform these duties are not called upon as part of their employment to perform or assist in emergency medical care of first aid or to be potentially exposed in some way. 

Physical Effort: May require prolonged sitting, walking, PC use. Require working under fast-paced and condition and deadlines. 

Mental Effort: Considerable amount of mental effort and concentration required, primarily in planning and organizing own work and in assisting departmental personnel. A great deal of judgement is needed in coordinating activities within the department and between departments.

PERFORMANCE RESPONSIBILITY:

In performing job functions associate will comply with all applicable laws, rules, regulations, as well as Unity Health policies and procedures.

TECHNICAL COMPETENCE (Weight: 40)

1. Organizes and leads the Ancillary/Outpatient Performance Improvement Initiative
   1. Works with Administrative/Departmental Leadership to:
      1. Monitor important aspects of the provision of care, treatment and services
      2. Identify opportunities for improvement

2. Performance Improvement and Facilitation Skills: 
   1. Effectively charters PI workgroups to focus on selected improvement opportunities
   2. Provides just in time training to newly formed PI workgroups
   3. Utilizes PI tools and techniques to lead teams through the FOCUS-PDCA process 
   4. Maintains focus of improvement efforts on the established scope of the project
   5. Implements ongoing measurement of activities to ensure sustain improvement

3. Oversees Daily Department-level Safety Huddles and Weekly Improvement Huddles
   1. Works with Department Directors to design and implement daily safety huddle process
   2. Monitors daily safety huddles and coaches directors to maximize the effectiveness of the huddles.

4. Oversees Weekly Improvement Huddles
   1. Works with Directors to design and implement visual management boards
   2. Works with Directors to design and implement weekly improvement huddle process
   3. Aggregates data in support of Department Improvement initiatives for display on visual management boards
   4. Monitors weekly improvement huddles and coaches unit directors to maximize the effectiveness of the huddles.

5. Assists Administrative and Departmental with regulatory compliance activities
   1. Maintains a working understanding of relevant regulatory requirements
   2. Conduct mock surveys on nursing units to ensure compliance with regulatory standards
   3. Participates in policy, procedure and protocol development to support regulatory compliance
   4. Represents the Ancillary/Outpatient Departments on Regulatory Surveys

6. Performance Improvement Team Membership and/or Support: 
   1. Participates as an effective member or support resource within performance improvement and value enhancement teams as assigned. 
   2. Provides pertinent data and information to the team as requested and as 

      available through current information systems. 

7. Hospital-wide Performance Improvement Resource:

Assists in the abstraction and submission of data as needed in the Ancillary/Outpatient settings.  Functions effectively as an information resource for data sources, compilation and display of data. 

QUALITY (Weight: 30)

1. Accuracy and Timeliness:

Complete assignments with a minimum of errors and within specified timeframes. 

1. Routinely checks work for content and corrects any errors detected prior to  

submission to Quality/Risk Management Director. 

2. Identifies and communicates any known sources of system error or variation 

to Quality/Risk Management Director and to involved departments, as requested by     

      Manager/Director. 

100. Works effectively in collaboration with departmental personnel to correct  

system errors.

2. Communication Skills: 

Communicates with co-workers in a manner that is conducive to positive and effective working relationships. Demonstrates respect, honesty, and integrity when working with other service providers as well as confidential information. 

1. Verbal interactions are conducted in a professional and productive manner. 
2. Written communication is clear, concise and checked for grammatical, punctuation and spelling accuracy prior to submission. 
3. Demonstrates effective speaking and listening skills. 
4. Asks for clarification and/or assistance from Quality/Risk Management Director when task requirements are unclear. 

3. Participates in continuous quality improvement. 
   1. Identifies variation in statistical retrieval and information gathering process and  

            notifies appropriate personnel. 

2. Presents solutions to eliminate variations. 
3. Implements solutions. 
4. Monitors process to determine success of solutions implemented. 

4. Contributes to a positive work climate and the overall quality effort of the department  

      and the medical center. 

1. Works well with department members. 
2. Works well with associates to ensure quality in areas of telephone communication, preparation of forms/correspondence, coordination of services and department wide computer adaptations/functions. 
3. Works well with other departments to ensure quality in the collection and distribution of information. 
4. Performs related responsibilities as required or directed.

5. Maintenance of Confidentially:

Demonstrates compliance with all relevant hospitals, state and federal requirements related to maintenance of confidentiality of persons, data and information systems. 

1. Does not breach patient or medical staff confidentiality. 
2. Does not disclose confidential information to any person(s), institution(s), or vendor(s) without the direct consent of the involved and/or approval from an authorized hospital representative. 
3. Does not discuss confidential matters in public areas. 
4. Complies with all hospital policies on data and health information security.  

6. Ongoing Professional Development:

Takes advantage of opportunities made available through UNITY HEALTH and other professional organizations for continued professional growth and development.  

1. Attends Unity Health continuing education offerings as appropriate. 
2. Participates in personal planning for ongoing professional development. 

7. Performs additional responsibilities as needed. 

CUSTOMER SERVICE (Weight: 30)

1. Identifies problems or dissatisfaction of customers and works to solve them to high degree of customer’s satisfaction. 
   1. Responds promptly to all customer issues. 
   2. Accurately captures information regarding problems.
   3. Follow-ups by measuring satisfaction of solutions to insure customers have the best possible service.

2. Decisions affecting customers are made to support their best interest. 
   1. Consults customer, when possible, as to their preference. 
   2. Gives full explanations to insure customer’s understanding. 
   3. Bases decisions and actions taken on customer preference.
3. Effectively turns a negative situation into supportive relationships by use of concern, poise, understanding and tact.
   1. Identifies and documents negative situations. Forwarding information to appropriate personnel for action. 
   2. Recognizes customer’s legitimate right to complain; encouraging opportunities for expressing them.
   3. Turns a problem into positive outcomes.

4. Exhibits behavioral skills promoting a positive guest relations environment. 
   1. Excellence and outstanding performance in highly visible every day.
   2. Responds to the needs of customers by meeting or exceeding mutually agreed deadlines for follow up.
   3. Reacts non-defensively when handling complaints and thanks customers for bringing issues to our attention.
   4. Demonstrates professional etiquette, interaction with physicians and other staff maintaining confidentiality.
   5. Recognizes the customer’s perception is right from their perspective and responds from that point of view.
   6. Demonstrates behavior that is positive, friendly and helpful. 
   7. Actively listens through various ways for opportunities to improve customer’s experience; i.e., personal contact, phone calls, complaint management forms, patient satisfaction surveys. 
   8. Works within organizational structure to solve customer problems, recognizing at time the appropriate need to bypass certain steps to achieve customer satisfaction. 
   9. Presents a professional appearance and exemplifies medical center standards of honesty and ethical behavior. 
   10. Utilizes appropriate strategies to facilitate positive change. 

ATTENDANCE / TARDINESS 

ATTENDANCE:   Exhibits dependability and reliability in work attendance.

(*Occurrence = any unscheduled or unapproved absence from work.)

1. Full-time Employees
2. Meets Standards:   Three or less occurrences in a floating 12-month period.
3. Needs to Improve:  Four or more occurrences in a floating 12-month period.

Subject to termination at seven occurrences in a floating 12-month period.

2. Part-time Employees
   1. Meets Standards:   Two or less occurrences in a floating 12-month period.
   2. Needs to Improve:  Three or more occurrences in a floating 12-month period.

Subject to termination at five occurrences in a floating 12-month period.

TARDY:  Reports to work promptly and as scheduled.

(*Incident = tardiness; defined as arriving at the work station any time after the scheduled starting time, leaving work prior to the designated quitting time or extending breaks or lunches without prior approval.)

1.  Full-time Employees
   1. Meets Standards:    Five or less incidents in a floating 12-month period.
   2. Needs to Improve:  Six or more incidents in a floating 12-month period.

Subject to termination at twelve incidents in a floating 12-month period.

2.      Part-time Employees

1. Meets Standards:   Three or less incidents in a floating 12-month period.
2. Needs to Improve:   Four or more incidents in a floating 12-month period.

Subject to termination at eight incidents in a floating 12-month period.