Job DescriptionAbstracts, analyzes, interprets and presents data to identify opportunities and support project goals. Assists with JCAHO and regulatory compliance. Effectively uses performance improvement tools and techniques to achieve desires outcomes. Facilitates performance improvement activities of the system, medical staff and operating unit. Facilities teams through a change in process or culture, using appropriate tools and techniques, to support the Inova Health System mission, strategic initiatives and operational priorities. Leads, plan, develops, implements and evaluates performance improvement, patient safety and regulatory activities to support Inova's mission, strategic initiatives and operational priorities. Provides JCAHO and Regulatory support. Provides facilitation support to teams and customers. Provides leadership and consultative services to departments in achieving regulatory, accreditation, and organizational compliance in quality and in performance management and improvement activities. Provides performance improvement consulting services to customers. Serves as an educational resource on quality, patient safety and regulatory issues. Tracks and monitors compliance. Support performance improvement initiatives to promote a culture of safety in all clinical area and disciplines. Use and develop appropriate tools and strategies to analyze and present in the area of performance improvement. Uses appropriate quality tools and techniques to analyze and present data.Status: FTShift:DaysSchedule:M-F, rotating weekendsJob Responsibilities Abstracts and analyzes data using available data systems, applications and medical records.Maintains proficiency with appropriate data systems and applications.Validates completeness and accuracy of data.Identifies potential concerns.Presents data and information in a way that is understandable, identify trends and patterns, and drives improvement.Facilities department/service line to identify meaningful quality, safety, and performance indicators.Researches and recommends appropriate benchmarks and best practices.Conducts ad hoc analyses, as needed, to support the needs of specific projects or information requests.Maintains appropriate confidentiality of data and information. Provides effective education and training programs as evidenced by customer satisfaction.Provides effective survey preparation and coordination as evidenced by survey outcomes.Identifies and implements appropriate PI tools to drive improvement.Facilitates root cause analyses and FEMAs, as appropriate.Identifies outlier cases and facilitates the review process.Guides individuals and teams to identify, analyze and understand sources and reasons for variation in current processes.Identifies appropriate benchmarks and best practices.Supports performance improvement activities tied to system and operating unit priorities and goals. Support medical staff department(s)/section(s)/ongoing professional practice evaluation and peer review quality improvement committee(s) that are accountable to oversee the quality of patient care, treatment, and services provided by practitioners with privileges.Understands how data utilized for quality improvement are generated.Extracts and interprets data, validating completeness and accuracy and identifies potential concerns.Presents data in a format that the customer understands.Assist the medical, department, and committee leaders in establishing priorities, selecting indicators to be monitored, managing the flow of information, and ensuring follow-up on action items.Prepares medical records, agenda, minutes, and other supporting documentation as required.Demonstrates professionalism by maintaining appropriate confidentiality of performance improvement data and information.Provides departments and committees with current trends, benchmarks, best practices to ensure that performance improvement activities are data-driven and evidence-based as appropriate.Assists physicians, leaders, and others in studying and understanding the effects of variation within clinical processes.Provides effective facilitation of PI Teams, medical staff meetings, FEMA, Quality Council as evidenced by the manager, and customer evaluation.Collaboration with medical staff, nursing/ancillary staff, and organizational leadership in identifying complex quality and safety of care issues in order to develop action plans and outcome measures.Keeps objectives in focus and moves teams to decisions as they relate the objectives.Uses appropriate tools and techniques to provide structure to the discussion, ie, agendas, fast PDCA, multi-voting, brainstorming, etc. Effectively lead teams to improve processes or culture, including PI teams, safety teams, medical staff, quality councils, etc. linked to the system and operating unit priorities and goals.Guides senior leaders, medical staff, clinical leaders, and other key stakeholders to identify, analyze and resolve complex quality, patient safety, and regulatory compliance issues.Leads and/or participates on committees and task forces supporting quality and safety goals.Exercises project management skills, appropriate tools, and techniques to facilitate group discussions and ensure progress towards project goals.Identifies areas requiring improvement and facilitates the development of action plans.Establishes priorities and manages information to achieve goals.Evaluates effectiveness and sustainability of interventions.Ensures follow-up on action plans.Maintains balance among multiple projects with respect to appropriate prioritization, resources, and timeline.Provides effective education and training programs as evidenced by customer satisfaction and number of educational programs held. Participates in SMART Program as evidenced by participation in at least 1 mock survey and one SMART presentationProvides effective survey preparation and coordination as evidenced by survey outcomes.Keeps abreast of current Joint Commission standards and other accreditation standards.Leads and/or participates on committees, task forces relative to Joint Commission and regulatory compliance.Serves as an educational resource and consultant to physicians, staff, and management related to regulatory standards.Provides facilitation support to teams and customersProvides effective facilitation of PI Teams, QRT's, Meeting management, medical staff meetings, FMEA, Quality Council as evidenced by manager observation, customer evaluation and self-assessmentCollaborates with medical staff, nursing/ancillary staff, and organizational leadership in identifying complex quality and safety of care issues in order to develop action plans and outcome evaluations.Keeps objectives in focus and moves teams to decisions as they relate to the objectives. Serves as a content expert and a resource for compliance priorities regulatory bodies.Proactively educates leadership and staff regarding regulatory issues, new statutes, guidelines, and safety/quality/PI activities.Provides effective facilitation services as evidenced by customer satisfaction.Effectively presents information to a group or in written form as evidenced by direct supervision, customer evaluation and self-assessmentMonitors clinical and safety outcomes related to real or potential events.Effectively facilitates peer review activities as evidenced by indicator development for all supported physician groups, reappointment data provided for re-credentialing, manager observation, self-assessment, and customer evaluation.Provides education on the use of performance improvement tools and methods.Provides effective education and training programs as evidenced by customer satisfaction.Assists assigned areas in developing and monitoring performance improvement indicators as evidenced by the percent of compliance in assigned areas.Effectively facilitates physician performance review;/peer review activities as evidenced by indicator development for all supported physician groups, reappointment data provided for re-credentialing, manager, and customer evaluation. Provides education on the use of performance improvement tools and methods. Serves as a champion and change agent for clinical quality and safety by appropriately challenging current processes, policies and procedures.Seeks to incorporate system and process changes to improve overall effectiveness.Serves as an educational resource on quality, patient safety and regulatory issues.Keeps abreast of current literature, quality and regulatory measures, standards and requirements.Educates and serves as a resource to staff, physicians, and leadership on performance improvement, patient safety and regulatory standards.Monitors and assures compliance with regulatory requirements.Provides consultative services to achieve quality, safety and regulatory requirements and goals.Creates meaningful presentations and reports to share information and findings.Support performance improvement initiatives to promote a culture of safety in all clinical area and disciplines.Coordinated and participates in the collection of data from appropriate sources including but not limited to medical records and safety logs.Coordinates and facilitates the FEMA and/or Root Cause Analysis processes.Assists in the identification of specific organization/department safety needs and priorities to foster and promote a safe and harm-free patient environment.Organizes compiles and reports quality and safety data to measure and evaluate patient safety.Tracks and trends patient safety in the operating unit.Act as a resource to staff on patient safety issues.Educates staff, physicians, and leadership on safety strategies and regulatory standards related to patient safety.Monitors and assures regulatory compliance in with national patient safety goals.Works with appropriate leaders and staff to establish priorities and recommend action plans to improve safety activities.Assimilates, evaluates, prepares and submits reports on time.Analyzes data appropriately as evidenced by written reports and customer evaluation.Uses appropriate computer applications in data analysis and to facilitates data-based decision making.Organizes compiles and reports quality and safety data to staff, physicians and leadership to identify trends, establish priorities and recommend improvement activities.Uses quality tools and techniques to assist teams and assigned areas to achieve desired outcomes as evidenced by outcomes and manager and customer evaluation.Utilizes quality tools and techniques to assist teams and assigned areas to achieve desired outcomes as evidenced by outcomes and customer satisfaction.Assimilates, evaluates, prepares and submits reports on time.Utilizes quality tools and techniques to assist teams and assigned areas to achieve desired outcomes as evidenced by outcomes and customer satisfaction.Analyzes data appropriately as evidenced by written reports and customer evaluation Analyzes data appropriately as evidenced by written reports and customer evaluationUses appropriate computer applications in data analysis and to facilitates data-based decision making.Uses appropriate tools and techniques to present data as evidenced by customer evaluation and manager observationAdditional RequirementsEducationBachelors Degree in related fieldExperienceMinimum of two years of experience in Healthcare/HospitalityKnowledge and experience in PI concepts, and tools, root cause analysis, facilitation of workgroup.About UsInova is Northern Virginia's leading nonprofit healthcare provider. Our mission is to provide world-class healthcare - every time, every touch - to each person in every community we have the privilege to serve. Inova's 18,000 team members serve more than 2 million individuals annually through an integrated network of hospitals, primary and specialty care practices, emergency and urgent care centers, outpatient services and destination institutes.Safety Always: Learn how we keep our team members and patients Safe@Inova.