Performance Excellence Manager

POSITION:                Manager of Performance Excellence

DEPARTMENT:       Performance

HOURS:                     1.0 FTE

Position Summary:  Responsible for overseeing and coordinating the development, implementation, and integration of functions, systems and processes that facilitate organizational performance and excellence including: Clinical and organizational quality, patient safety; risk management; infection prevention; case management; regulatory compliance; quality/process improvement; data and information management; organizational learning; and medical staff functions and services, including credentialing.


  • Registered Nurse Required, BSN Preferred
  • 5 years experience as a Registered Nurse in a Hospital setting with experience in quality/performance improvement or related quality field preferred.
  • Current licensure in the State of Minnesota as a Registered Nurse


  • Ability to utilize verbal and written communication skills in order to address external and internal customers, including senior management and various other individuals
  • Negotiate, instruct, supervise, persuade and influence people
  • Ability to manage data and information using data management principles
  • Ability to develop communication tools for performance improvement
  • Active listening, conflict management and team building
  • Proficiency in planning, organizing, delegating and communicating departmental goals and work plans as they relate to the overall mission
  • Strong clinical skills, mentoring abilities
  • Capable of managing daily challenges in a rural health care setting
  • Demonstrated effective presentation skills, written communication and computer skills
  • Ability to delegate appropriately and effectively
  • Ability to compile well organized, summarized data reports.
  • Ability to assimilate massive amounts of data to glean the most salient points.
  • Ability to independently plan and execute priorities, is highly organized, and manages multiple priorities well.
  • Manages time well and meets timelines for deliverables.
  • Maintains proficiency in use of software required to obtain analyze, and display data to the satisfaction of the organization, e.g. Excel, Word, PowerPoint, and databases.

General Responsibilities:

  1. Performance Excellence and Improvement:  In collaboration with the Chief Medical Officer and Senior Leadership coordinate and facilitate a comprehensive effective organizational excellence program.
    1. Develop an annual performance excellence and improvement plan that outlines systems and processes to implement knowledge management and performance improvement concepts and principles.
    2. Collaborate with leaders in the development of performance improvement strategies that support and integrate the organization’s strategic plan.
    3. Design and facilitate the implementation of a performance management system that identifies criteria, indicators and outcomes to measure clinical, nursing, service and processes to improve performance and drive organizational excellence.
    4. Assure data and information related to the organizational excellence program is in accordance with data management principles, including promoting the use of statistical tools and techniques and data driven decisions.
    5. Serve as the organizational expert and develop educational curricula and training related to performance improvement concepts and principles for leaders, medical staff and staff.
    6. Develop systems and coordinate processes to assure accuracy, integrity and timely submission for all publicly reporting clinical, quality, and patient safety data and information.
    7. Serve as a lead facilitator for identifying and coaching performance improvement and process teams.
    8. Serve on all performance improvement and quality related functions committees to provide consultative support, including coordinating and facilitating the Performance Excellence Committee with the Chief Medical Officer.
  2. Patient Safety/Risk Management:  In collaboration with the Chief Medical Officer and Senior Leadership, coordinate and facilitate an evidence based program and processes to assure a highly reliable organization.
    1. Serve as the organization’s Patient Safety Officer and designs, develops and facilitates the implementation of written patient safety plan that describes organizational systems and processes designed to prevent and/or reduce the risk of healthcare adverse events.
    2. Ensure the implementation and compliance with all applicable national patient safety goals, published sentinel events and other recommended reduction strategies for patient safety.
    3. Facilitate and assist leaders in conducting risk assessments to identify proactively organizational risks using nationally recognized frameworks such as failure, mode and effect analyses.
    4. Assist in the design and implementation of patient safety and event reporting systems to identify adverse events and facilitate root cause analyses and corrective action plans for such using nationally recognized framework and processes.
    5. In collaboration with the Chief Medical Officer, design educational curricula and programs to train leaders and staff on principles of high reliability.
    6. Develop an organizational risk management program and plan that describes processes to reduce risk and/or liability for the organization and processes for loss prevention and claims management.
  3. Medical Staff:  Support the Chief Medical Officer and the medical staff in assuring effective processes to evaluate clinical competence and medical staff performance improvement.
    1. Oversee the credentialing processes to assure effective and timely medical staff appointments and reappointments.
    2. Assist the Chief Medical Officer in the development and implementation of focused and ongoing professional practice evaluation systems.
    3. Oversee the medical staff peer review processes.
  4. Service Excellence:  Assist organizational leaders in the development of service excellence and service recovery programs that utilizes the voice of the customer/patient to design patient centered delivery systems and to improve organizational performance.
    1. Assure the development and implementation of a patient compliant/feedback process that is in compliance with current conditions of participation.
    2. Assist in the aggregation, identification of trends and patterns, and communication of patient satisfaction data and information.
    3. Facilitate service excellence teams as commissioned by the Performance Excellence Committee.
  5. Regulatory Compliance:  Lead the organization in assuring ongoing and continuous compliance to regulatory entities.
    1. Serve as the internal resource for interpretation and implementation of CAH Conditions of Participation, including conducting annual CAH evaluation of services and facilitating annual review of policies and procedures.
    2. Assist departmental leaders in the development of department quality programs in accordance with CAH Conditions of Participation.
    3. Assist leaders in the development of policies and procedures required by regulatory standards.
    4. Coordinate all surveys and required deliverables.
  6. Management/Supervisory:In collaboration, lead the Organizational Excellence Department to assure quality related functions are developed, integrated and implemented effectively across the organization.
    1. Supervise and manage the medical staff services coordinator, infection preventionist, data analyst and the care management, assuring these functions have well defined written programs, plans and policies and procedures which are developed using evidence based research and practices, and implemented efficiently and effectively across the organization.
    2. In collaboration with the Chief Medical Officer, develop an annual budget for the department and oversee the operational implementation of the budget.
    3. Is accountable for staff recruitment, development, and retention.  Interviews and hires staff.  Completes and  signs employee evaluation forms.  Supervises and evaluates staff performance.  Writes and administers annual performance appraisals on department staff.
    4. Authorizes and administers coaching/counseling and disciplinary to staff.  Provides guidance and constructive criticism as needed.  Renders discipline as dictated by CCMH’s policies i.e. progressive discipline: coaching-verbal warning-written warning-final written warning-suspension- termination.
    5. Represents CCMH management and responds to and adjusts grievances in the Performance Excellence areas.
    6. Validates time and attendance (time cards) and approves PTO/vacation requests.
    7. Coordinates and assigns job duties, scheduled work hours and schedule changes and approves overtime.
    8. Promotes staff within the departments and approves of interdepartmental and intradepartmental transfers.
    9. Supervises and evaluates work performance in accordance with job description of all personnel assigned.  Monitors staff competency and continuing education participation.
    10. Nominates department staff for the GEM award when they go above and beyond and recognizes and rewards staff whenever possible.
    11. Develops, implements, monitors and evaluates ongoing  performance excellence and improvement programs