Overview

Our Magnet®-designated nurses have received multiple awards of excellence for keeping our patient care at the forefront of national best practices!  The Performance Improvement Coordinator is responsible for facilitating the performance improvement and patient safety activities in accordance with accreditation, regulatory and other requirements, including continually monitoring requirements, practices and medical staff/hospital needs for the purpose of modifying monitoring activities. Responsible to perform initial screening and analysis of reported events, conduct data abstraction, and facilitate meaningful case review and documentation. Implements and monitors physician and organization performance improvement specific tracking, trending and reporting. Analyzes trends and identifies key measures; acts upon trends and measures identified. Collaborates with the Medical Staff and other clinical leaders to assure compliance with regulatory and accreditation requirements. Facilitates high reliability and identifies care variation. Incumbent has comprehensive and advanced clinical, data analysis, and organizational skills.

Responsibilities

• Facilitates and supports performance improvement (PI) and patient safety initiatives or assigned area to promote clinical excellence and patient safety.
• Performs complex analysis and trending of data through review of reported events, case screening, and data abstraction.
• Prepares and designs meaningful reports that include statistical analysis, interpretation, monitoring and benchmarking of clinical data.
• Attends in-service training sessions and seminars to maintain and improve knowledge of performance improvement techniques.
• Designs and maintains database system for compilation and reporting of program metrics with incorporation of benchmarks and comparative data.
• Develops meaningful dashboards and reports for departments, divisions, committees and staff.
• Utilizes with a high degree of competence PI methodology and PI tools such as flow mapping, fish bones, root cause analyses to facilitate and drive process improvement in an expert manner.
• Reviews charts for quality concerns including adverse occurrences. Establishes timelines and exercises discretion and judgment when identifying concerns for review to improve processes.
• Performs chart review to identify if variation from quality of care exists and to determine the need for peer review.
• Identification of cases for peer review and education to promote quality of patient care.
• Investigates quality of care concerns from providers, payers and patients/ families.
• Supports several medical staff departments and major clinical areas with performance improvement initiatives and quality outcomes.
• Develops and monitors action plans.
• Participates in other initiatives and programs and performs other duties as assigned by the Director of the department.
• Responsible to maintain confidentiality of sensitive information.
• Attends in-service training sessions and seminars to maintain and advance knowledge of performance improvement techniques.

Requirements

• Associate Degree/Diploma in Nursing with ten years of health-care quality experience or
• Bachelor Degree in Nursing, Health-care Administration or other health-care related field preferred with five years of Staff RN/LPN in an acute care environment with three years experience in quality management or other discipline with substantially similar responsibilities.
• Licensed NJ RN required.
• Highly Analytical with strong grasp of both qualitative and quantitative data skills.
• Excellent coaching, organizational, interpersonal, verbal and written communication and conflict resolution skills.
• Intermediate to advanced computer skills.
• Experience with data analysis and management of clinical databases.

About Capital Health

Capital Health is Mercer County, New Jersey region's leader in advanced medicine with significant investments in advanced technologies and the best physicians. Comprising its two hospitals (Capital Health Regional Medical Center in Trenton and Capital Health Medical Center - Hopewell) and the Capital Health - Hamilton outpatient facility, Capital Health is a growing accredited healthcare organization. Capital Health has also received Magnet® status for the fifth consecutive time in recognition of its quality patient care, innovations in professional nursing practice, and nursing excellence. As the most honored Magnet organization in our region, Capital Health is one of only 34 organizations worldwide to have achieved Magnet recognition five or more times. In addition, our nursing team received special recognition for excellence in stroke and outpatient emergency care.

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