Title:Assistant Vice President - Performance Measurement
Req Number:chmc-1
Department:Quality Improvement Systems / 11-190200
Job Grade:M-5

Start Time AM/PM:8:00 AM
End Time AM/PM:5:00 PM
Work Shift:1st shift
Hours Per Week:40

Salary:-
Location(s):Cincinnati OH

PURPOSE OF POSITION: To direct and implement a sustainable strategy for measuring and improving the outcomes of care delivery across business units and clinical divisions; to further the organizational work of medical staff performance based privileging, provider performance measurement, outcomes measurement, ratings/rankings and transparency initiatives, and electronic health record development using clinical standardization, evidence, outcomes and lean process concepts to change the outcome for our patients.

Business Unit Performance Improvement
1. Incorporate strategic improvement goals of Clinical System Improvement (CSI) and Patient Safety teams into business unit improvement priorities, focusing on vertical alignment of organizational improvement work.

2. Assist business units and clinical divisions in prioritizing and implementing quality measures and related improvement activities, and support enterprise-wide improvement projects by successfully aligning business unit and clinical division metrics with organizational improvement initiatives, goals and targets.

3. Facilitate development of business unit and clinical division performance improvement infrastructure, suggesting workable structures and processes, identifying areas for improvement, and implementing outcomes measurement systems valued by internal constituents and their patients and external customers.

4. Assist business units with preparation of quarterly updates to Cabinet regarding quality measures and related improvement activities (, data analysis and display, comparative benchmarks, evidence summaries, etc.).

5. Prepare Cabinet feedback to each Business Unit regarding their quality initiatives after each cycle of Cabinet presentations. Prepare follow up assignments and orient Clinical Effectiveness staff to them.

Provider Performance Measurement
6. Advise Medical Staff Services and medical staff leadership in the development of provider specific performance measures to be used for performance based privileging, medical staff reappointment, and specialty board maintenance of certification.

7. Incorporate strategic improvement goals of Clinical System Improvement (CSI) and Patient Safety teams into provider level performance assessment activities of clinical divisions, focusing on vertical alignment of improvement work and leveraging provider capability to move the dial on performance.

8. Conduct practice pattern analysis and benchmarking studies to identify opportunities for clinical standardization and improvement in clinical practice by reducing provider-specific variation.

9. Serve as a liaison between the medical staff leadership, organizational leadership, and clinical divisions to foster the sharing and dissemination of learning including improvement science, provider assessment methods, pay-for-performance arrangements, and transparent reporting of performance to regulatory, accrediting, and payor audiences.

Outcome Measurement/ Ratings, Rankings and Transparency
10. Develop, implement and monitor clinical outcomes measures for evidence based care teams and organizational performance improvement and patient safety teams and initiatives.

11. Orchestrate the work of clinical chart reviewers and data analysts to provide clinical and process data supporting outcomes monitoring and improvement for evidence based care, patient safety, and lean/process initiatives chartered by the organization.

12. Coordinate clinical data collection and reporting so as to enable operational divisions and patient care units to establish the capability to improve care.

13. Conduct just-in-time training as needed in improvement theory, methods and appropriate selection and use of measurement tools.

14. Contribute to the demonstration of the business case for quality by providing chart review data, literature review and evidence summaries, and comparative benchmarks supporting such efforts at the institutional, divisional/business unit, and project-specific levels.

15. Participate in the development of system-level outcome measures that leverage our market position, academic reputation, standing with regulators, and preserve/enhance our economic leverage with managed care organizations.

16. Orchestrate our participation in national comparative benchmarking surveys such as Leapfrog and US News & World Report, as well as measurement related initiatives sponsored by NACHRI and CHCA, and multicenter studies sponsored by AHRQ and National Quality Forum.

17. Orchestrate our organizational response to public reporting requirements sponsored by accrediting bodies and regulatory agencies.

18. Conduct quality audits to maximize data quality, validity, and integrity when used for outcomes monitoring and reporting.

19. Identify 'best practice' organizations and measurement initiatives to support comparative benchmarking efforts.

Preparatory Work for Electronic Health Records
20. Support the organizational strategic initiative to develop electronic health records by providing project leadership for anticipatory improvement work in clinical standardization, selection of evidence based outcomes, development of planned/chronic care delivery models, and lean information and clinical process flow to optimize the utility of electronic health records used in ambulatory settings.

21. Work with faculty leaders and organizational champions to develop, vet, and implement horizontal standardized outcome measures for incorporation into electronic records to further organizational comparative benchmarking and public reporting requirements.

22. Provide project leadership/consultation to clinical divisions to identify condition-specific evidence-based outcomes for inclusion in electronic records.

23. Ensure that horizontal and condition-specific measures are sufficiently drilled down to include leveraging of provider performance to drive improvement in outcomes.

24. Coordinate all decisions in collaboration with HPCE faculty leaders, organizational champions, and Information Services to optimize organizational effectiveness and economy of effort in selection of appropriate metrics.

25. Ensure that work is scoped and trade-offs in priorities are balanced to favor parsimony, and that staff resources to accomplish this work in a timely fashion are adequately anticipated.

Staff Management
26. Ensure that a sufficient number of qualified and competent persons are available to accomplish the goals of the department.

27. Manage the selection, development, motivation, evaluation and discipline of reporting personnel. Ensure that job requirements and goals for each position are clear to employees. Determine and document the qualifications and competence on a continuing basis.

28. Provide leadership, mentoring and coaching of reporting personnel with the goal of developing the skills needed to facilitate achievement of team goals and enterprise-wide strategic priority goals.

29. Ensure that orientation, in-service training and continuing education are provided to division personnel to achieve satisfactory levels of competence.

30. Develop management staff to maximize the strengths and abilities of each.

31. Determine and monitor implementation of continuing education goals of the division. Promote professional input to in-service training programs, both for clinical and non-clinical staff.


Other Duties and Responsibilities
32. Demonstrate productive relationships with business unit leaders, improvement project sponsors, and internal network of quality consultants and content experts.

33. Participate in improving organizational performance through recommending areas or approaches for improvement activities, performing new procedures, collecting test data, and providing input to department discussions.

34. Conduct quality assurance activities to maximize data quality, validity, and integrity of data used for outcomes monitoring.

35. Collaborate with Planning and Business Development, Marketing, Finance, and Payor Relations in leveraging quality data to increase market share/revenue.

36. Identify and make recommendations to management on resources required to support improvement efforts, both 'centralized' and distributed within business units and clinical divisions.

37. Maintain currency in the field by reviewing literature and attending seminars and participating in continuing education. Implement this knowledge in Health Policy & Clinical Effectiveness.

38. Contribute to the improvement of community-based health care systems through participation in professional, private or government groups.

39. Ensure compliance with policies and procedures protecting patient rights for informed consent and the handling of confidential information as defined by Cincinnati Children's mission and applicable laws and regulations.

40. Participate in establishing job requirements and goals; perform duties at the desired level of competency.

41. Ensure that work areas are organized and present a safe, accessible, effective and efficient environment for employees, patients and families.

42. Attend required Cincinnati Children's training sessions, including radiation safety, laboratory safety, bloodborne pathogens and OSHA.

43. Comply with Infection Control policies and procedures.

44. Understand, adhere to and model Core Standards of behavior as defined organizationally and specifically within the department/unit.

45. Perform other duties as assigned.

REQUIRED SKILLS: Strong leadership, mentoring and project orchestration skills including drive-to-completion, production-focus, and delivering high quality work products by established deadlines while mindful of organizational economy of effort. Must be self-directed, results-oriented, innovative and flexible. Demonstrated ability to be successful within matrix organizational structures. Possess working knowledge of the development, testing, and refining of measures at the individual patient, population, and system levels, data management, quality improvement tools and methods of data analysis and display that is sufficient to inform the work and roles of those in direct reporting relationships and provide expert coaching to others in the organization. Previous experience working with clinicians (both physicians and nurses) in an academic medical center to foster improvement work. Demonstrated ability to lead and manage a department of at least 10 people. Proficient team leadership skills ' goal setting, and evaluating, coaching, guiding, mentoring and rewarding employees. Demonstrated quality improvement, organization development and management skills. Demonstrated understanding of quality improvement, measurement and analytic processes, techniques and tools. Demonstrated skills in building positive relationships with senior leaders, managers and employees, and community leaders and members. Excellent written and oral communication skills, adapted to situation/context and organizational hierarchy. Ability to interpret, implement and develop CCHMC policies and procedures.

EDUCATION/WORK EXPERIENCE: Master's degree or PhD in Clinical Epidemiology, Health Services Administration, Public Health, Psychometrics or relevant discipline required. Minimum 10 years related experience. Prior operational and supervisory experience within a complex medical center preferred. Prior experience with electronic medical records preferred.