JOB SUMMARY 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.PRIMARY JOB RESPONSIBILITIES Job responsibilities labeled EF capture those duties that are essential functions of the job.PEOPLE - 20%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)Collaborates in an interdisciplinary manner on hospital-wide patient safety, performance improvement, and data management/analysis functions to maximize outcomes. (EF)SERVICE - 20%Leads accreditation readiness initiatives. Participates in regulatory and accreditation surveys. (EF)Serves as a resource for basic data analysis. Develops summary reports and assists with presentation of findings to various audiences. (EF)Coordinates the agenda and meeting materials for the quality and patient safety committees of the hospital for assigned areas. (EF)QUALITY/SAFETY - 40%Maintains all programs to ensure compliance to accreditation standards and regulatory agency requirements. (EF)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)Concurrently reviews and analyzes inpatient records to ensure that compliance to quality indicators is met. (EF) Provides basic analyses of hospital performance against patient safety, quality and outcomes measures. (EF)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)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)Conducts record review for performance improvement, peer review, patient safety, risk management and other projects. (EF)FINANCE - 5%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%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. EDUCATION REQUIREMENTS
- Bachelor of Science or higher degree in Nursing required
CERTIFICATES, LICENSES AND REGISTRATIONS REQUIRED
- Three years of experience in a hospital or outpatient clinical role
- One year of experience in a quality management and/or patient safety, risk management, decision support or similar information analysis role
- Texas RN license or temporary TX RN license, should obtain permanent license within 90 days. Compact license acceptable according to current Board of Nursing requirements.
- Certified Professional in Healthcare Quality, Certified Professional in Patient Safety, or other related professional certification preferred