Performance Improvement Specialist RN - Quality CareManagement

At Houston Methodist the PerformanceImprovement Specialist is responsible for the development ofperformance improvement / patient safety initiatives.

Promotesorganization wide understanding of the overall quality and patientsafety program and culture. Facilitates timely and effectiveresolutions of patient care issues.

Serves as a resource to alllevels of the organization relative to quality improvementactivities conducting or providing education as requested by staffor leadership.

Coordinates teams as needed to drive change towardsdesired outcomes using appropriate performance improvementmethodologies.

PEOPLE ESSENTIALFUNCTIONS

• Collaborates withEducation on instructing / informing staff on new or revised qualityprograms or plans regulatory and accreditation standards and / orperformance improvement processes asapplicable.
• Collaboratesin an interdisciplinary manner on hospitalwide patient safetyperformance improvement and data management / analysis functions tomaximize outcomes.

SERVICEESSENTIAL FUNCTIONS

• Leadsaccreditation readiness initiatives. Participates in regulatory andaccreditationsurveys.
• Serves as aresource for basic data analysis. Develops summary reports andassists with presentation of findings to variousaudiences.
• Coordinates theagenda and meeting materials for the quality and patient safetycommittees of the hospital for assignedareas.

QUALITY / SAFETYESSENTIALFUNCTIONS

• Maintains allprograms to ensure compliance to accreditation standards andregulatory agencyrequirements.
• Abstractspertinent information and enters into department databases usingstandardized methods and processes. Routinely performs discrepancymanagement activities to maintain data integrity.

Presentsmeaningful reports and analysis with measurement descriptionstatistical information and benchmarking information.

Reports datato external agencies asneeded.

• Concurrentlyreviews and analyzes inpatient records to ensure that compliance toquality indicators ismet.
• Provides basicanalyses of hospital performance against patient safety quality andoutcomesmeasures.
• Utilizes resultsfrom performance improvement activities to identify and prioritizeareas of focus for improvement. Evaluates and provides input on theeffectiveness of performance improvementprograms.
• Supportsimprovement efforts for potential or actual quality of care / riskissues including participation / facilitation of Root Cause Analysis(RCA) Failure Modes Effects Analysis (FMEA) or event review asneeded.

Supports leadership and staff with the development andimplementation of process changes. Summarizes events and presentsfindings as needed.

Facilitates systems design to hardwire patientsafety processes.

Conductsrecord review for performance improvement peer review patientsafety risk management and otherprojects.

FINANCE ESSENTIALFUNCTIONS

Proactivelyidentifies quality and safety improvement opportunities throughanalysis of internal and external data to include federal incentiveprograms asapplicable.

GROWTH / INNOVATIONESSENTIAL FUNCTIONS

Designs developsand implements project plans related to strategic quality andsafety initiatives. Manages reporting of these projects / measures tointernal departments / committees and / or outside agencies as needed.

Provides oversight for these projects to ensure desirable outcomesare met.

This job description is notintended to be allinclusive; the employee will also perform otherreasonably related business / job duties as assigned.

HoustonMethodist reserves the right to revise job duties andresponsibilities as the needarises.

EDUCATION

Bachelorof Science or higher degree in Nursingrequired

WORKEXPERIENCE

• Three years ofexperience in a hospital or outpatient clinicalrole
• One year ofexperience in a quality management and / or patient safety riskmanagement decision support or similar information analysisrole

LICENSES ANDCERTIFICATIONS REQUIRED

• RNRegistered Nurse Texas State Licensure and / or Compact StateLicensure within 90 days OR
• RNTemp Registered NurseTemporary State Licensure within 90 days

LICENSESAND CERTIFICATIONSPREFERRED

• CPHQ CertifiedProfessional in Healthcare Quality (NAHQ) OR
• CPPS CertifiedProfessional in Patient Safety (CBPPS) OR
• or other relatedprofessional certification preferred

KNOWLEDGE SKILLSAND ABILITIES

• Demonstratesthe skills and competencies necessary to safely perform theassigned job determined through ongoing skills competencyassessments and performanceevaluations
• Sufficientproficiency in speaking reading and writing the English languagenecessary to perform the essential functions of this job especiallywith regard to activities impacting patient or employee safety orsecurity
• Ability toeffectively communicate with patients physicians family members andcoworkers in a manner consistent with a customer service focus andapplication of positive languageprinciples
• Knowledge ofstatistical analysis techniques andsoftware
• Knowledge ofperformance improvement methodologies andprinciples
• Knowledge ofthe principles of patientsafety
• Knowledge ofaccreditation and regulatory agencies requirements for performanceimprovement and patientsafety
• Ability to learnand apply use of databases for aggregation of data foranalysis
• Strong leadershipqualities (task completionmotivation)
• Ability toindependently analyze and solveproblems

SUPPLEMENTALREQUIREMENTS

WORKATTIRE

• UniformNo
• Scrubs No
• Businessprofessional Yes
• Other (department approved)No

ONCALL*

• Notethat employees may be required to be oncall during emergencies (ie.DIsaster Severe Weather Events etc) regardless of selectionbelow.
• On Call*No

TRAVEL

Travelspecifications may vary bydepartment

• May requiretravel within the Houston Metropolitan areaYes
• May require travel outside HoustonMetropolitan areaYes

CompanyProfile :

Houston Methodist TheWoodlands Hospital opened in June 2017 as the eighth hospital inthe Houston Methodist system. This 267bed 725000squarefootfullservice acutecare hospital offers many of the same services asour flagship hospital in the Texas Medical Center.

• Also on thebeautiful hospital campus located at the intersection of Interstate45 and Texas State Highway 242 are two medical office buildingswhich include a Breast Care Center;
• Cancer Center; infusion center;heart and vascular services; neurology; orthopedics and sportsmedicine; rehabilitation services;

wellness services; an outpatientlaboratory; and several other multispecialty physician practices.In January 2022 Houston Methodist The Woodlands opened HealingTower a $250 million expansion project that added 106 beds focusedon medicalsurgical and womens services and provided nine operatingrooms.

The project also included the expansion of the endoscopycenter emergency department and diagnostic imaging department withan enhanced neurodiagnostic and interventionalcenter.

Houston Methodist is an equal opportunityemployer inclusive of women minorities disabled persons andveterans.

Equal EmploymentOpportunity

Houston Methodist isan Equal Opportunity Employer.

Equal employmentopportunity is a sound and just concept to which Houston Methodistis firmly bound. Houston Methodist will not engage indiscrimination against or harassment of any person employed orseeking employment with Houston Methodist on the basis of racecolor religion sex sexual orientation gender identity nationalorigin age disability status as a protected veteran or othercharacteristics protected by law.

VEVRAA Federal Contractorpriority referral Protected Veteransrequested.