Responsibilities
POSITION SUMMARY:
The Director of Performance Improvement is responsible for supporting and advancing hospital-wide quality, patient safety, regulatory compliance, and performance-improvement initiatives. The Director of Performance Improvement works collaboratively with nursing leadership, physicians, clinical staff, case management, risk management, infection prevention, and other departments to identify opportunities for improvement, analyze clinical data, implement evidence-based interventions, and evaluate outcomes.
The position plays an important role in promoting a culture of patient safety, continuous quality improvement, evidence-based practice, and regulatory readiness within the hospital.
POSITION REQUIREMENTS AND QUALIFICATIONS:
Education: Bachelor of Science in Nursing (BSN) degree required; MSN preferred.
Licensure/Certification: Current New York State Registered Professional Nurse (RN) license.
DUTIES/RESPONSIBILITIES:
- Monitor and analyze clinical quality and patient-safety indicators, including adverse events, hospital-acquired conditions, readmissions, falls, pressure injuries, medication-related events, and other relevant measures.
- Collect, validate, trend, and report quality data to identify patterns, risks, and opportunities for improvement.
- Participate in hospital-wide and department-specific Performance Improvement (PI) projects.
- Assist clinical departments in developing and implementing corrective and preventive action plans.
- Facilitate Root Cause Analyses (RCA), Failure Mode and Effects Analyses (FMEA), and other structured quality-improvement methodologies as appropriate.
- Collaborate with interdisciplinary teams to develop, implement, and evaluate evidence-based interventions.
- Monitor compliance with hospital policies, clinical standards, and applicable New York State and federal requirements.
- Support regulatory and accreditation readiness, including preparation for surveys and reviews by applicable regulatory and accrediting organizations.
- Review medical records and clinical documentation for quality, safety, and compliance opportunities.
- Develop and present quality reports, dashboards, trends, and performance-improvement findings to nursing leadership, quality committees, and other stakeholders.
- Educate and coach staff regarding quality standards, patient-safety practices, performance-improvement processes, and evidence-based care.
- Participate in quality and patient-safety committees and multidisciplinary meetings.
- Assist with development and revision of policies, procedures, protocols, and clinical guidelines based on current evidence and identified quality needs.
- Track improvement initiatives through measurable outcomes and ensure sustainability of successful interventions.
- Promote a non-punitive culture of safety and encourage staff reporting of safety concerns and improvement opportunities.
- Maintain appropriate documentation of quality activities, findings, action plans, and follow-up.
- Perform other duties related to quality improvement and patient safety as assigned.
- Ensures compliance with Infection Prevention and Control Polices and Precautions, safe work practices, and engineering controls as outlined in the Infection Control Policy & EOC Policies.
- Formulates and implements policies and procedures for Nursing.
- Reviews all Policies and Procedures in order to insure evidence based practice
- Recommends changes in policies, techniques, procedures, etc. to improve nursing care and educational programs.