Performance Improvement Specialist - Accreditation

At Houston Methodist the 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

• Provide 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.

• Practices the Caring and Serving Model

• Delivers personalized service using HM Service Standards

• Provides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET Managing Up Key Words)

• Intentionally collaborates with other healthcare professionals involved in patients/customers or employees experiential journeys to ensure strong communication ease of access to information and a seamless experience

• Involves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given job

• Actively supports the organizations vision fulfills the mission and abides by the I CARE values

PEOPLE ESSENTIAL FUNCTIONS

• 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.

• Collaborates in an interdisciplinary manner on hospitalwide patient safety performance improvement and data management/analysis functions to maximize outcomes.

SERVICE ESSENTIAL FUNCTIONS

• Leads accreditation readiness initiatives. Participates in regulatory and accreditation surveys.

• Serves as a resource for basic data analysis. Develops summary reports and assists with presentation of findings to various audiences.

• Coordinates the agenda and meeting materials for the quality and patient safety committees of the hospital for assigned areas.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Maintains all programs to ensure compliance to accreditation standards and regulatory agency requirements.

• 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.

• Concurrently reviews and analyzes inpatient records to ensure that compliance to quality indicators is met.

• Provides basic analyses of hospital performance against patient safety quality and outcomes measures.

• 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.

• 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.

• Conducts record review for performance improvement peer review patient safety risk management and other projects.

FINANCE ESSENTIAL FUNCTIONS

• Proactively identifies quality and safety improvement opportunities through analysis of internal and external data to include federal incentive programs as applicable.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• 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.

This job description is not intended to be allinclusive; 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

• Bachelor of Science or higher degree in Nursing required

WORK EXPERIENCE

• 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

LICENSES AND CERTIFICATIONS REQUIRED

• RN Registered Nurse Texas State Licensure and/or Compact State Licensure within 60 days OR
• RNTemp Registered Nurse Temporary State Licensure within 60 days

LICENSES AND CERTIFICATIONS PREFERRED

• CPHQ Certified Professional in Healthcare Quality (NAHQ) OR
• CPPS Certified Professional in Patient Safety (CBPPS) OR
• or other related professional certification preferred

KNOWLEDGE SKILLS AND ABILITIES

• Demonstrates the skills and competencies necessary to safely perform the assigned job determined through ongoing skills competency assessments and performance evaluations

• Sufficient 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

• Ability to effectively communicate with patients physicians family members and coworkers in a manner consistent with a customer service focus and application of positive language principles

• Knowledge of statistical analysis techniques and software

• Knowledge of performance improvement methodologies and principles

• Knowledge of the principles of patient safety

• Knowledge of accreditation and regulatory agencies requirements for performance improvement and patient safety

• Ability to learn and apply use of databases for aggregation of data for analysis

• Strong leadership qualities (task completion motivation)

• Ability to independently analyze and solve problems

SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE

• Uniform No
• Scrubs No
• Business professional Yes
• Other (department approved) No

ONCALL*
*Note that employees may be required to be oncall during emergencies (ie. DIsaster Severe Weather Events etc) regardless of selection below.

• On Call* No

TRAVEL**
**Travel specifications may vary by department**

• May require travel within the Houston Metropolitan area Yes
• May require travel outside Houston Metropolitan area Yes

Since 1998 Houston Methodist Sugar Land Hospital has been serving Fort Bend and the surrounding counties. Residents have come to rely on a level of compassionate care and leadingedge technology that was once available only in the Texas Medical Center. Houston Methodist Sugar Land Hospitaltied for No. 4 in Houston and No. 6 (threeway tie) in Texas in U.S. News & World Reports best hospital rankings in 2020.With 316 operating beds 24 operating rooms and over 2400 employees Houston Methodist Sugar Land Hospital was designed to provide comprehensive personalized care for the community.