Job Description

ECU Health

About ECU Health Medical Center

ECU Health Medical Center, one of four academic medical centers in North Carolina, is the 974-bed flagship hospital for ECU Health and serves as the primary teaching hospital for The Brody School of Medicine at East Carolina University. ECU Health Medical Center has achieved Magnet® designation twice and provides acute and intermediate care, rehabilitation and outpatient health services to a 29-county region that is home to more than 1.4 million people.

Position Summary

Apply improvement methods to achieve successful outcomes: Use evidence-based structured improvement methods for all quality improvement projects. Promote the use of improvement methods and science throughout the organization. Support the use of a standard improvement method throughout the organization. Coach others on the implementation of improvement methods.

Apply project management methods, knowledge of Ongoing Professional Practice Evaluation (OPPE), and applicable regulations and standards to assist with development of system-wide sustainable action plans in partnership with physician and APP leadership; develop project timelines, research and recommend performance indicators and targets; use valid and reliable data to support recommendations and illuminate key trends for stakeholders.

Demonstrate expertise to ensure key databases are current related to specifications that may impact database results; validate accuracy of data retrieved from databases utilizing sound data collection/validation techniques, provide education, mentorship, and coaching for others to learn and utilize the databases to maximize efficiency.

Responsibilities:

1. Demonstrate expertise in the use of analytical and statistical tools and techniques including understanding of how process goals are established, measured and monitored; maintain responsibility to manage databases including specifications, training and communication related to those databases; apply techniques and tools to identify variation and its causes; analyze input variable to identify critical factors that must be addressed to achieve optimal process performance; train others to apply analytical and statistical methods.

2. Synthesize information from relevant resources including national organizations to demonstrate current practice and identify opportunities for improvement. Identify sources of valid and reliable information and metrics to monitor performance trends. Analyze information from disparate sources. Analyze comparative data, benchmarks, and evidence-based practices for possible adaptation into the organization. Use valid and reliable data to support opportunity recommendations and illuminate key trends for stakeholders. Design solutions to address opportunities based on benchmarks, goal comparison, data analysis, and correction actions. Advise on future data and information needs and resources to better support improvement initiatives.

3. Produce routine reports from both internal and external databases; stay current and ensure databases are current related to specifications that may impact database results; validate accuracy of data retrieved from databases utilizing sound data collection/validation techniques; provide mentorship and coaching for others to learn and utilize the databases to maximize efficiency and spread knowledge and awareness of data availability.

4. Communicate improvement priorities and results using narrative and visual tools by create graphs and charts that accurately reflect valid interpretation of findings; develop dashboards and scorecards to depict internal metrics and benchmark comparisons; create written and verbal communication to tell a story appropriate to the audience; develop system-wide dashboards and scorecards incorporating clinical and business metrics to strategic or operational goals.

5. Gain expertise in public reporting such as various ratings and rankings; appropriately access data from public reporting organizations; learn and be able to communicate the specifications as related to publicly reported databases; validate the accuracy of publicly reported data; interpret and communicate results for various levels of expertise including front line staff, community members, leadership, and board members; speak to the varying methods utilized by public reporting agencies and how those affect the data results; develop ways to utilize real time internal data to parallel publicly reported data; integrate the data in to the action plans and performance improvement strategies; collaborate with other departments to ensure the efficiency of data downloads/uploads as well as overall use of data from publicly reported agencies.

6. Design and develop project plans including project coordination using project management tool, measurement plan, estimate costs to determine budget, incorporates evidence-based guidelines. Use change management principles. Communicates project progress to all stakeholders through the project. Train process owners, team members, and sponsors on implementation action/measurement plans.

7. Foster an environment of continued learning by contributing to education programs; provide expertise for planned and systematic educational opportunities; plan and develop training efforts ensuring appropriate use of learning strategies; collaborate with other departments to meet educational needs throughout the organization; coordinate training programs throughout the system and outside the organization as needed.

8. Adopt and model an environment with strategic communication woven throughout all education, performance improvement and consulting activities; ensure communication is proactive, detail oriented and action driven; establish productive relationships throughout the organization and when serving as a representative with local, state, and national organizations; lead the effort to close gaps in communication for programs and projects; mentor others in sound communication strategies.

9. Promote a safety culture and infrastructure by engaging stakeholders to understand all perspectives when addressing patient safety issues; model behaviors that promotes a safety culture; educate staff; support adoption of high reliability principles; coach staff and leaders on those principles; design sustainable actions to improve patient safety; build cohesive patient safety program that includes evidence-based practices.

10. Apply methods to identify and evaluate risks for harm by using assessment tools and methods appropriate for identification of potential and actual patient safety risks including RCA and FMEA; conducts fact-based investigations; monitors actions to prevent recurrence; uses improvement methods to improve patient safety reporting and processes; collaborates with risk, legal, senior leadership and regulatory as appropriate; establishes proactive processes, policies and educational programs to improve patient safety program.

11. Conduct audits to ensure compliance; utilize education techniques (such as just-in-time training) during audits to enhance knowledge and understanding of standards with front-line staff; provide analysis of compliance to assist with development of sustainable action plan in partnership with leadership; develop process for early identification of areas that are not in compliance; communicate results to leadership as an action plan for compliance; provide education on regulations and standards to stakeholders.

12. Facilitate the development and monitoring of action plans for noncompliant findings including assisting with the preparation of an action plan in response to survey or audit reports; develop data collection tools for auditing/monitoring measures of success/compliance with standards; develop methods for communicating action plans and results to key leaders and stakeholders; analyze action plans to validate their effectiveness.

13. Apply knowledge of ongoing professional practice evaluation, focused professional practice evaluation, and requisite structures and processes including applying applicable regulations and standards to OPPE and FPPE work, coordinating reviews for OPPE and FPPE processes; develop processes to support practitioner practice reviews; incorporate evidence based practices into OPPE and FPPE, collaborate with practitioner leaders to established structure and processes; engage clinical leadership by providing consultations on concerns for review, follow up, and action plans.

14. Support efforts during planned and unannounced surveys; Monitor compliance with licensed bodies and other accrediting standards; assist with site visits and prepare required documents; develop data collection tools for auditing/monitoring measures of success/compliance with standards; analyze and interpret data to support key leaders and stakeholders in action planning process.

15. Advance a continuous readiness culture by leading in readiness activities; integrate continuous readiness activities into everyday workflows; conduct continuous readiness rounding and tracers; provide training and education; facilitate presentations for leaders and medical staff; implement/develop program to promote continuous readiness in everyday workflow.
Independence and Leadership skills

16. Independently manages individual work

17. Demonstrates self-direction in area of assigned responsibility

18. Assists with department oversight to include peer coaching and mentoring

19. Helps lead the development of goals and strategies

20. Identifies improvement opportunities and leads improvement projects

21. Actively promotes collaboration and seeks to learn from others

22. Demonstrates ability and willingness to assume leadership responsibilities with the organization

23. Build effective relationships and collaborations with front-line staff and management to promote continued learning and support.

24. Accountability in the following areas:

• Accepts responsibility for actions and decisions
• Acknowledges and corrects own mistakes
• Follows through on assignments, projects, or requests
• Pays attention to details. Completes work, which is thorough and accomplishes desired result
• Stays current with best practice standards, guidelines, regulatory standards, and local/state/federal law
• Accountable for an effective program

Minimum Requirements

• Masters degree in healthcare/business related field- or higher.
• >5 years experience in healthcare setting

Other Information

• Monday-Friday 8a-5p; Hybrid option after orientation period is complete with department
• No On-Call, No Weekends, No Holidays
• Position Office located in Greenville (GLC Building)

General Statement

It is the goal of ECU Health and its entities to employ the most qualified individual who best matches the requirements for the vacant position.

Offers of employment are subject to successful completion of all pre-employment screenings, which may include an occupational health screening, criminal record check, education, reference, and licensure verification.

We value diversity and are proud to be an equal opportunity employer. Decisions of employment are made based on business needs, job requirements and applicant's qualifications without regard to race, color, religion, gender, national origin, disability status, protected veteran status, genetic information and testing, family and medical leave, sexual orientation, gender identity or expression or any other status protected by law. We prohibit retaliation against individuals who bring forth any complaint, orally or in writing, to the employer, or against any individuals who assist or participate in the investigation of any complaint.

Contact Information

For additional information, please contact:

Braeton Grady, Talent Acquisition Consultant

ECU Health Talent Acquisition

Email: [email protected]