Supervisor of Performance Improvement and Compliance-Emergency Department Administration, Full Time Days

Facility Manager

Cape Fear Valley Medical Center

Location : Fayetteville, North Carolina

Department : Emergency Department Administration

Job Family : Management

Work Shift : Days (United States of America)

Summary : Performance Improvement Serves as a resource for the Emergency Department for Performance Improvement (PI). Supports the management of quality and performance improvement through participation in and coordination of activities related to use toward improvement of clinical and work processes. Regulatory Serves as a resource for the Emergency Department on Joint Commission and CMS standards. Assists in overseeing constant preparedness for Joint Commission, CMS, and other regulatory inspections.

Major Job Functions

The following is a summary of the major essential functions of this job. The incumbent may perform other duties, both major and minor, that are not mentioned below. In addition, specific functions may change from time to time :

• Serves as a resource for PI teams, PS Teams and Regulatory Teams.
• Works with PI / PS Team Leaders, Facilitators, and Teams to provide ongoing education related to process and data analysis.
• Uses flowcharts, Pareto charts, cause and effect diagrams, check sheets, scatter diagrams, and histograms as needed to interpret data.
• Collects, reviews and analyzes data while monitoring processes and identifies opportunities for improvement.
• Reviews, audits, and compiles reports utilizing the following data : EMTALA, Restraints, Sedation, Disease specific accreditation requirements, ED Quality Metrics.
• Use various elements of corrective and preventive action to improve processes.
• Completes background information and participates in ACA (Apparent Cause Analysis), RCA (Root Cause Analysis), and ERTs (Event Response Team) as designated.
• Assists with the tri-annual Joint Commission survey within the organization and CMS and DHHS surveys when they occur.
• Coordinates education programs on Performance Improvement, Patient Safety, and Regulatory related subjects as appropriate.
• Other duties as assigned.

Minimum Qualifications

The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job :

Education and Formal Training :

Work Experience :

Knowledge, Skills, and Abilities Required :

Physical Requirements :

Required Licenses and Certifications : RN - Board Of Nursing

Cape Fear Valley Health System is an Equal Opportunity Employer M / F / Disability / Veteran / Sexual Orientation / Gender Identity