Coordinator, Performance Improvement (Quality)

About the role

Coordinates quality, performance and operational improvement activities to assess and review care/services provided and compliance with organizational and regulatory standards and requirements. Provides ongoing monitoring and evaluation of the level of patient care/organizational services and operations.

Responsibilities

• Coordinates and provides reporting of quality/performance/operational review activities and issues in accordance with established guidelines.
• Performs studies to assess conformance to specifications, standardization of processes, performance measures, best practice and safety standards.
• Collaborates with the assigned Director and leadership staff to select specific topics for review, such as problem procedures, drugs, high‑volume cases, high‑risk cases, or other factors.
• Assists in establishing review criteria and standards for measuring and monitoring level of care and services, ensuring compliance with hospital, Joint Commission, and regulatory agency requirements.
• Executes the review process:
  • Identifies, selects, and obtains medical charts/records for review, applying quality review criteria to collect data, analyze, and prepare reports.
  • Performs concurrent review to identify, investigate, and report unexpected outcomes, risk‑management or sentinel events, infection‑control information, and variations from expected criteria.
• Evaluates workflows, including work queuing, scheduling, operational practices, space design, layout, inventory, and resource management.
• Conducts specific studies of patient/operational processes and compliance with policy/procedure when complications or unexpected trends appear.
• Assists in establishing priorities and makes recommendations for improvement activities to ensure compliance with standards of practice and Joint Commission/regulatory requirements.
• Supports implementation of corrective action for non‑compliance.
• Utilizes analytic skills and statistical analysis to aggregate data, identify potential problems, patterns, and trends, establish priorities, and recommend improvement activities.
• Works collaboratively with nursing, medical, and hospital staff to obtain information and resolve problems regarding quality and efficiency of patient care and organizational services.
• Participates in the organization’s accreditation procedures by reviewing data and reports and making recommendations to ensure compliance with Joint Commission and other regulatory requirements.
• Provides administrative support for special projects and studies; collects and compiles data, performs statistical analysis, and follows up as needed.
• Prepares and maintains required reports, records, and files for operational, administrative, and compliance purposes.
• Utilizes computer and information systems to enter, format, and retrieve data, generating statistics, tables, charts, and graphs.
• Assesses the environment, personnel, internal operations, and processes to determine approaches that coordinate people, equipment, and materials to achieve quality and efficient operations.
• Serves as a resource and liaison between departments and participates on quality/performance improvement committees to ensure the organization’s overall PI plan implementation and compliance.
• Conducts staff in‑services, training, and orientation on PI processes, tools, techniques, and accreditation standards.
• Maintains professional credentials and education necessary to stay current with clinical, theoretical, and performance‑improvement principles, best practices, and trends; attends continuing education, staff development, and mandatory programs.

Qualifications

• Professional credentials and ongoing education in clinical, theoretical, or performance‑improvement fields.
• Knowledge of hospital, Joint Commission, and regulatory compliance standards.
• Experience with quality, performance, and operational review activities in a healthcare setting.
• Proficiency in analytic and statistical methods for data aggregation and trend analysis.
• Ability to use computer and information systems for data entry, reporting, and visualization.
• Strong collaboration and communication skills for working with nursing, medical, and administrative staff.