Work Shift: DAY
Work Week: M - F
At Houston Methodist, the NTW Performance Improvement Specialist is responsible for the development of performance improvement/patient safety initiatives. Promotes organization wide understanding of the overall quality and patient safety program and culture. Facilitates timely and effective resolutions of patient care issues. Serves as a resource to all levels of the organization relative to quality improvement activities, conducting or providing education as requested by staff or leadership. Coordinates teams as needed to drive change towards desired outcomes using appropriate performance improvement methodologies.
PATIENT AGE GROUP(S) AND POPULATION(S) SERVED
Refer to departmental "Scope of Service" and "Provision of Care" plans, as applicable, for description of primary age groups and populations served by this job for the respective HM entity.
HOUSTON METHODIST EXPERIENCE EXPECTATIONS
oProvide personalized care and service by consistently demonstrating our I CARE values:
-INTEGRITY: We are honest and ethical in all we say and do.
-COMPASSION: We embrace the whole person including emotional, ethical, physical, and spiritual needs.
-ACCOUNTABILITY: We hold ourselves accountable for all our actions.
-RESPECT: We treat every individual as a person of worth, dignity, and value.
-EXCELLENCE: We strive to be the best at what we do and a model for others to emulate.
oFocuses on patient/customer safety
oDelivers personalized service using HM Service Standards
oProvides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET, Managing Up, Key Words)
oIntentionally rounds with patients/customers to ensure their needs are being met
oInvolves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given job
PRIMARY JOB RESPONSIBILITIES
Job responsibilities labeled EF capture those duties that are essential functions of the job.
PEOPLE - 20%
1.Collaborates with Education on instructing/informing staff on new or revised quality programs or plans, regulatory and accreditation standards, and/or performance improvement processes as applicable. (EF)
2.Collaborates in an interdisciplinary manner on hospital-wide patient safety, performance improvement, and data management/analysis functions to maximize outcomes. (EF)
SERVICE - 20%
1.Leads accreditation readiness initiatives. Participates in regulatory and accreditation surveys. (EF)
2.Serves as a resource for basic data analysis. Develops summary reports and assists with presentation of findings to various audiences. (EF)
3.Coordinates the agenda and meeting materials for the quality and patient safety committees of the hospital for assigned areas. (EF)
QUALITY/SAFETY - 40%
1.Maintains all programs to ensure compliance to accreditation standards and regulatory agency requirements. (EF)
2.Abstracts pertinent information and enters into department databases using standardized methods and processes. Routinely performs discrepancy management activities to maintain data integrity. Presents meaningful reports and analysis with measurement description, statistical information, and benchmarking information. Reports data to external agencies as needed. (EF)
3.Concurrently reviews and analyzes inpatient records to ensure that compliance to quality indicators is met. (EF)
4.Provides basic analyses of hospital performance against patient safety, quality and outcomes measures. (EF)
5.Utilizes results from performance improvement activities to identify and prioritize areas of focus for improvement. Evaluates and provides input on the effectiveness of performance improvement programs. (EF)
6.Supports improvement efforts for potential or actual quality of care/risk issues including participation/facilitation of Root Cause Analysis (RCA), Failure Modes Effects Analysis (FMEA), or event review as needed. Supports leadership and staff with the development and implementation of process changes. Summarizes events and presents findings as needed. Facilitates systems design to hardwire patient safety processes. (EF)
7.Conducts record review for performance improvement, peer review, patient safety, risk management and other projects. (EF)
FINANCE - 5%
1.Proactively identifies quality and safety improvement opportunities through analysis of internal and external data, to include federal incentive programs as applicable. (EF)
GROWTH/INNOVATION - 15%
1.Designs, develops, and implements project plans related to strategic quality and safety initiatives. Manages reporting of these projects/measures to internal departments/committees and/or outside agencies, as needed. Provides oversight for these projects to ensure desirable outcomes are met. (EF)
This job description is not intended to be all inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.
oBachelor of Science or higher degree in Nursing required
oThree years of experience in a hospital or outpatient clinical role
oOne year of experience in a quality management and/or patient safety, risk management, decision support or similar information analysis role
CERTIFICATES, LICENSES AND REGISTRATIONS REQUIRED
oTexas RN license or temporary TX RN license, should obtain permanent license within 90 days. Compact license acceptable according to current Board of Nursing requirements.
oCertified Professional in Healthcare Quality, Certified Professional in Patient Safety, or other related professional certification preferred
KNOWLEDGE, SKILLS AND ABILITIES REQUIRED
oDemonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
oSufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
oAbility to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
oKnowledge of statistical analysis techniques and software
oKnowledge of performance improvement methodologies and principles
oKnowledge of the principles of patient safety
oKnowledge of accreditation and regulatory agencies requirements for performance improvement and patient safety
oAbility to learn and apply use of databases for aggregation of data for analysis
oStrong leadership qualities (task completion, motivation)
oAbility to independently analyze and solve problems
Other (dept approved) No
On-Call* No (for Non-Exempt or Exempt jobs)
*Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Event, etc) regardless of selection above.
May require travel within Yes
Houston Metropolitan area
May require travel outside Yes
of Houston Metropolitan area
**Travel specifications may vary by department.
Please note any other special considerations to this job: __________________________
Equal Employment Opportunity
Houston Methodist is an Equal Opportunity Employer.
Equal employment opportunity is a sound and just concept to which Houston Methodist is firmly bound. Houston Methodist will not engage in discrimination against or harassment of any person employed or seeking employment with Houston Methodist on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, status as a protected veteran or other characteristics protected by law.
VEVRAA Federal Contractor - priority referral Protected Veterans requested.
Houston Methodist Baytown Hospital, located 35 miles southeast of Houston, is the area's only full-service hospital offering specialized medical care for patients at every stage in life. This 392 licensed bed hospital with 18 operating rooms, and over 1,400 employees, brings Medical Center excellence and quality care close to East Harris and surrounding counties.