Performance Improvement/Survey Coordinator
Bristol Bay Area Health Corporation - Dillingham, AK

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Provides a wide variety of support services to BBAHC including identifying, planning, and executing Performance Improvement projects. Maintains a high state of preparedness for accrediting body surveys.

  • College Degree required.
  • Must possess knowledge of specific laws and regulations imposed on healthcare systems by various agencies.
  • RN, with equivalent quality improvement training or BSN Certified Professional in Healthcare Quality preferred.
  • Must have four years’ hospital experience, with at least one year in corporate compliance, performance improvement, or accrediting body survey coordinator.
  • Knowledge of analysis of data to identify patterns and trends is necessary. This includes ability to abstract, compile, and interpret Government Performance Results Act (GPRA) data.
  • Able to support and enhance Performance Improvement efforts through the use of quality improvement tools, statistics, and data analysis.
  • Able to facilitate teams crossing multiple departments and functions.
  • Communications skills, both written and oral, with a functional knowledge of medical terminology required.
  • Must exercise discretion and maintain confidentiality as governed by HIPAA and HITECH.
  • Prior IHS /PHS or Federal hospital experience and/or rural hospital experience is desirable.
  • Thorough knowledge of current accrediting body standards and programs is required.

  • Essential Functions:
  • Serves as the organization’s GPRA Coordinator.
  • Maintains awareness of laws, standards and regulations affecting healthcare through education and peer contact.
  • Develops and implements system-wide Performance Improvement programs, policies and procedures to ensure compliance with applicable federal and state laws and agency regulations.
  • Directs all aspects of BBAHC’s Performance Improvement program including planning, designing and/or evaluating the principal program.
  • Provides guidance to key individuals relative to their responsibilities for Performance Improvement.
  • Builds and facilitates Performance Improvement teams. Assists team leads in developing and managing improvement projects.
  • Tracks Performance Improvement and Risk Management activities.
  • Conducts periodic analysis of comments received and events reported to identify emerging trends and recommends process changes to eliminate identified problem areas.
  • Supports managers in hypothesis and data-driven problem solving.
  • Reports and explains Performance Improvement projects to internal and external audiences.
  • Serves as a resource for all BBAHC Performance Improvement review processes. Guides staff in responding to recommendations or deficiencies, and monitors corrective actions for identified recommendations or deficiencies.
  • Assesses effectiveness of actions taken to implement recommendations or correct deficiencies.
  • Arranges and facilitates Performance Improvement team meetings when necessary to address complex issues.
  • In conjunction with the Chief Compliance Officer (CCO), other members of the healthcare team, and available resources facilitates: continuing improvement in the assessment and evaluation of the quality of patient care, formulation of plans to address assessed needs and issues, implementation of improvement plans, evaluation of the effectiveness of plans in meeting established care goals, and revisions of plans as needed to reflect changing needs, issues and goals.
  • Provides resources, education, and current material to all employees regarding Performance Improvement.
  • Educates others in the use of appropriate data collection and analysis methods to identify patterns and trends. Assists CCO in developing strategies to prevent, reduce, and respond to Quality of Care issues; identify process-oriented problems; improve continuity of care; and strive for positive outcomes.
  • Completes specific Performance Improvement and Risk Management projects delegated directly by the CCO in a timely manner.
  • Serves as Subject Matter Expert in accrediting body standards and processes, CMS Conditions of Participation, and related accreditations.
  • Informs BBAHC staff of changes, developments, and updates to accrediting body standards.
  • Assists BBAHC staff in preparations for accrediting body surveys, inspections including mock surveys, and assists in developing follow-up reporting in response to survey findings.
  • Evaluates survey preparation and follow up and monitors activities as necessary to ensure implementation of required changes. Assesses effectiveness of actions taken to implement recommendations or correct deficiencies.
  • Arranges and facilitates survey preparation team meetings when necessary to address complex issues.
  • Other duties as assigned.

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