SUMMARY: The Clinical Quality Performance Manager is responsible for planning, coordinating, monitoring, and improving clinical care and services for all AHS locations at the hospital. This position is responsible for leading clinical quality performance improvement initiatives. This role combines the clinical expertise required to change clinical practice and engage clinical and operational leaders with the leadership skills to influence clinical processes, systems, and outcomes. This position will examine effective Models of care delivery for opportunities for optimization and to decrease waste within the systems of care. Identifies opportunities for organizational wide improvements based on evidence-based practices, regulatory and accrediting agency requirements, and data analysis of high risk, high volume and/or problem prone processes. This position is responsible for negotiating timelines and priorities for projects, coordinating action plans, and monitoring/analyzing results for projects that are consistent with the organization's strategic goals and imperatives. Performs related duties as required.

DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: Following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.

1. Advises on the appropriate use of quality improvement tools and methodologies, such as PDCA, Lean, Six Sigma, and Statistical Process Control Analysis.

2. Conduct in-depth chart review of potential harm/ PSI cases and engage involved providers in final review and identification of potential gaps in care.

3. Evaluates data, makes judgments, and recommendations regarding quality improvement work, including but not limited to resource utilization, physician practice patterns, and clinical pathway effectiveness. In collaboration with the data analytics team, designs and develops dashboards and other innovative data visualization using business intelligence tools.

4. Identifies, designs and implements new processes and clinical care, based on evidence, to continually improve patient care and outcomes and to achieve performance targets.

5. Perform chart review and abstraction of clinical information to meet requirements for different National and State quality reporting programs and initiatives such as CMS Inpatient and Outpatient Quality Reporting, IPFQR, CMS Hospital Star Rating, and Leapfrog Safety Grade.

6. Performs data analysis; creates & interprets data displays, including clinical, cost, and patient satisfaction data. Works collaboratively with Information Technology (IT) Informatics team, Finance, Enterprise Data Warehouse / Business Intelligence team, Quality, and others to ensure the integrity and accuracy of the data that is utilized. Utilizes Microsoft programs, Crystal Reports, MIDAS, Vizient, EPIC, and other applications & databases.

7. Performs, coordinates, and facilitates quality improvement, patient safety activities, and clinical effectiveness initiatives for assigned projects to achieve unit/service goals, working collaboratively with physicians and staff of designated unit/service.

8. Provide subject matter expertise to clinical champions on various regulatory, patient safety, and quality reporting programs and initiatives in collaboration with the quality department.

9. Provides content knowledge in the interpretation, implementation, and maintenance of standards to match external requirements (e.g., Joint Commission, CMS, Title 22) in collaboration with the quality and regulatory departments.

10. Provides guidance in understanding and using AHS data models & systems, and acts as resource in the interpretation and use of data generated and utilized by the department in collaboration with the data analytics department.

11. Reviews AHS Accreditation, Risk, Safety and Quality/Performance Improvement Department quality goals to identify opportunities for improvement and to ensure current projects are working to meet organizational goals.

12. Support systemwide Nursing and Medical Staff quality and performance improvement activities such as NQRC, Peer Review, OPPE, and FPPE as required by regulatory agencies.

13. Support various clinical performance improvement teams such as Code Blue, Procedural Sedation, Stroke, and Sepsis by providing information on current evidence based practice, performance benchmarks, and clinical trends.

MINIMUM QUALIFICATIONS:
Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying.

Education: Bachelor's degree in a clinical or healthcare related field.

Minimum Experience: Three years of experience working in a healthcare setting preferably in an acute care hospital.

Preferred: Lean Six Sigma certification or Performance Improvement experience and /or training

Preferred Licenses/Certifications: Master's degree; Certified Professional in Healthcare Quality (CPHQ).

Required Licenses/Certifications: Current licensure in the State of California as a registered nurse.