Quality Patient Safety Program Manager - Clinical Lic

Overview

Baylor St. Luke's Medical Center is an internationally recognized leader in research and clinical excellence that has given rise to breakthroughs in cardiovascular care neuroscience oncology transplantation and more. Our team's efforts have led to the creation of many research programs and initiatives to develop advanced treatments found nowhere else in the world. In our commitment to advancing standards in an ever-evolving healthcare environment our new McNair Campus is designed around the human experience-modeled on evidence-based practices for the safety of patients visitors staff and physicians. The 27.5-acre campus represents the future of healthcare through a transformative alliance focused on leading-edge patient care research and education. Our strong alliance with Texas Heart Institute and Baylor College of Medicine allows us to bring our patients a powerful network of care unlike any other. Our collaboration is focused on increasing access to care through a growing network of leading specialists and revolutionizing healthcare to save lives and improve the health of the communities we serve.

Responsibilities

The primary function of the Quality/Patient Safety Program Manager is to support, coordinate, and facilitate the quality management (QM), patient safety (PS) and regulatory performance improvement (PI) activities for the hospital and medical staff. This role also serves as a resource to employees, management, nursing directors, senior management, councils, physicians and teams on quality management activities and will handle patient sensitive and confidential hospital information.

ESSENTIAL KEY JOB RESPONSIBILITIES

Assists in the design, planning, implementation and coordination of Quality Management, Patient Safety and Performance Improvement activities for assigned hospital and medical staff departments, committees, divisions, service lines and functions. Proactively coordinates and facilitates performance improvement teams to support key initiatives, including but not limited to, activities focused on clinical quality improvement, patient safety and risk reduction, patient experience, efficiency, FMEAS, root cause analyses and medical staff improvement (e.g. case review for peer review, OPPE, FPPE).

Participates in an integral role to ensure compliance with CMS HIQRP/HOQRP, TJC, Leapfrog, etc., data collection and reporting of process and outcome measures. Facilitates development and implementation of data collection tools and processes including the ability to: identify data elements needed to complete appropriate measurement, perform data collection and abstraction per specifications, and validate data prior to submission or preview reports prior to publication.

Facilitates meetings, presents data and reports, identifies key findings and assists with action plans and implementation. Maintains current knowledge of accreditation and licensing requirements and must be a resource to staff on these regulations in order to improve management of outcomes and ensure compliance. Assists with regulatory readiness and survey preparation activities including mock survey tracers.

Qualifications

Education and Experience Required:

• Licensed Registered Nurse, Licensed Clinical Pharmacist, or other Licensed Clinical Staff

• Three (3) years clinical experience in an acute care setting.

• One (1) year healthcare‐related quality management/performance improvement experience (e.g., chart audit, PI team member, etc.).

• Must be able to perform case reviews for medical staff peer review and medical and/or surgical Registry Abstraction.

Licensure and Certification Required:

• Licensed Registered Nurse, Licensed Clinical Pharmacist, or other Licensed Clinical Staff

• Current state license in a clinical field in state of practice.

• Certified Professional in Healthcare Quality (CPHQ), or Healthcare Quality and Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment is required.

Minimum Knowledge, Skills, and Abilities:

• Knowledge and expertise of quality management/performance improvement methods, tools, and techniques (e.g. PDSA, Tests of Change, Six Sigma, LEAN) and ability to create and support an environment that meets the quality goals of the organization.

• Current knowledge of data reporting and regulatory/accreditation requirements for acute and ambulatory care services and federal, state and local healthcare related laws and regulations and the ability to comply with these in healthcare practices and activities.

• Knowledge of effective self‐management practices and ability to manage multiple concurrent objectives, projects, groups, or activities, making effective judgments as to prioritizing and time allocation.

• Understanding of the necessity and value of accuracy and attention to detail. Must be able to review patient records and provide case summaries and maintain the confidentiality of the peer review process.

• Knowledge of the techniques and the ability to work with a variety of individuals and groups in a constructive and collaborative manner.

• Knowledge of the current situation or issue at hand; ability to take full personal responsibility or ownership for assignments, activities, decisions and results.

• Knowledge of techniques and tools that promote effective analysis and the ability to determine the root cause of organizational problems and create alternative solutions that resolve the problems in the best interest of the business.

• Ability to work well under pressure and respond to changing needs and complex environments.

• Excellent communication skills (oral and written), presentation style, including the ability to concisely present data to leaders, clinicians and staff at all levels of the organization.

Disclosure Statement:

The job summary and responsibilities listed above are designed to indicate the general nature of the work performed within this job. They are not designed to contain or be interpreted as a comprehensive inventory of all job responsibilities required of employees assigned to this job. Employees may be required to perform other duties as assigned.