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Performance Improvement Manager

Performance Improvement Manager

ID 
2017-8501
FutureCare Facility 
FutureCare Courtland
Position Type 
Regular Full-Time
Shift 
Days

Career Details

Overview

The Performance Improvement Supervisor works as a leader and innovator in improving care and services by coordinating and managing performance improvement while overseeing nursing care, fiscal management, and human resource management, in conjunction with the Director of Nursing.  This person may also serve as the risk manager and/or infection control coordinator for the facility.  This position oversees the daily nursing operations of the facility.  This position serves as the Director of Nursing in their absence.

Responsibilities

Duties and responsibilities of this position include, but are not limited to the following tasks and assignments:

 

  1. Performance Improvement – Responsible for the performance improvement (PI) program for the facility. 

 

  1. Supports and/or supervises implementation of the PI program to assure compliance with federal/state regulations.
  2. Assists and oversees department heads in identifying and prioritizing aspects of care/services, indicators and problems to assure compliance.
  3. Collaborates with Department Heads to evaluate results of monitoring activities and ensures follow up action until desired thresholds or standards are achieved.      
  4. Tracks identified departmental and multi-departmental problems until resolved.
  5. Develops and/or assists in improvement plans for deviations from standard.
  6. Identifies performance improvement issues and develops measures that address these areas.
  7. Assures annual calendar of PI activities is developed and followed.
  8. Assures appropriate use of all PI tools including Abaqis.
  9. Oversees or provides ongoing staff education in regards to the PI program.

10.  Reviews admissions, readmissions, transfers and discharges to identify potential quality of care issues.

11.  Reviews 24 hour report daily and follows up on any issues.

12.  Reviews the Quality Indicator Profile monthly to identify outliers and assists in improvement plans for deviations from the standard.

13.  Participates in monthly safety meeting.

14.  Utilizes facility policies, procedures and protocols to optimize performance activities.

15.  Upon approval of the Director of Nursing and Administrator, submits monthly summarized PI report to the appropriate Ombudsman.

16.  Submits monthly PI report to the Regional Clinical Services Manager.

 

  1. Unusual Occurrences – Monitors unusual occurrences in facility

 

  1. Assists in and maintains all relevant aspects of incidents, investigations and/or emergencies in the facility.
  2. Monitors Incident/Occurrence Reports and follows up on outcome.
  3. Performs trend analysis on occurrences monthly
  4. Identifies unsafe or incorrect practices of staff and institutes corrective action.

 

  1. Infection Control – May serve as Infection Control practitioner for facility (as directed by the Director of Nursing)..

 

  1. Maintains logs for antibiotics usage and reports monthly and quarterly.
  2. Monitors and reports cases of infectious illnesses i.e.:  diarrhea, flu.
  3. Coordinates the vaccination program to ensure residents and staff receive vaccinations as needed.
  4. Monitors and coordinates all aspects of Exposure Control Plan and Tuberculosis Plan including adherence to regulatory policies and procedures.
  5. Ensures all infection control documentation is maintained in a retrieval manner.

 

  1. Clinical Practice Management – Acts as a resource to the clinical team and utilizes the nursing process to promote improved nursing practice and quality resident care.  Supervises clinical aspects of nursing practice and engages in clinical activity.

 

  1. Acts as a role model and a resource to nursing staff in the management of complex resident problems.
  2. Assists nursing staff with decision-making in clinical situations.
  3. Monitors resident issues daily.
  4. Demonstrates clinical competency in care of residents.
  5.  Maintains and improves clinical knowledge base and skills to remain current in practice standards.

 

 

  1. Communication – Promotes effective relationships and communication with all staff, residents and families.

 

  1. Identifies and diffuses stressful/conflict situations related to verbal and non-verbal communication problems with follow up resolution.
  2. Reads and encourages others to read communication books, memos, and minutes.
  3. Interacts with others in a considerate, helpful, and courteous manner.
  4. Communicates clinical/safety problems and changes through communication books, posters, and memos.
  5. Communicates pertinent information and requests through established channels.
  6. Collaborates with the DON to identify clinical activities to facilitate the professional growth of staff.
  7. Communicates with DON on a regular basis, through verbal or written communication as appropriate.

 

  1. Administration – Sets and implements goals and policies consistent with the philosophy and purpose of the facility.

           

  1. Abides by the standards identified in FutureCare’s Statement of   Corporate Ethics and the Corporate Compliance Plan.
  2. Performs “administrative-call” duties as scheduled.
  3. Performs Unit Manager responsibilities (as needed for coverage) to include assignment and coordination of duties of nursing personnel based on resident care needs, available staff and unit needs.
  4. Oversees preparation of Hours of Duty based on staffing plans.  Submits copy of hours of duty to DON for review according to established time frame.
  5. In absence of staffing coordinator, makes changes in employees work schedule and arranges for adequate coverage when personnel are absent.
  6. Maintains a system of written communication for nursing staff that includes a process for determining that all communications have been reviewed by all nursing personnel.
  7. Assures that required documentation is completed in timely fashion.
  8. Assess need and assists in determining par levels for unit based supplies.
  9. Makes daily rounds evaluating care rendered and supervising staff.

10.  Attends weekly interdisciplinary conferences and gives nursing input to the residents’ plan of care.

11.  Participates in annual budget process by identifying staff and equipment needs for the next fiscal year.

 

  1. Human Resource Management: Responsible for personnel management in conjunction with the Unit Managers.

 

  1. Interviews and hires applicants for nursing positions according to policy, following EOE guidelines.
  2. Monitors attendance and lateness.
  3. Counsels employees on deficiencies in performance and attendance.
  4. Initiates disciplinary action in accordance with established policy. Handles grievances according to procedures as necessary.
  5. Coordinates and participates in new employee orientation.
  6. Conducts annual evaluations of unit personnel.

 

  1. Professional Development – Seeks opportunities for own growth and expansion of responsibilities.

           

  1. Attends meetings as directed.
  2. Participates in education workshops/programs to increase professional competence to meet professional goals.
  3. Presents neat appearance in appropriate dress and identification as required by position.
  4. Attends mandatory in-services.
  5. Must be willing to assume a Director of Nursing position if/as required.

 

Qualifications

  1. Current Maryland RN licensure
  2. Progressive experience in acute or long term care setting and proven leadership ability.
  3. B.S. degree in nursing preferred