Work Shift DAY Work Week M - F Job Summary 102018 JOB SUMMARY At Houston Methodist, the NTW Performance Improvement Specialist is responsible for the development of performance improvementpatient 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 patientcustomer safety oDelivers personalized service using HM Service Standards oProvides for exceptional patientcustomer experiences by following our Standards of Practice of always using Positive Language (AIDET, Managing Up, Key Words) oIntentionally rounds with patientscustomers to ensure their needs are being met oInvolves patients (customers) in shifthandoff 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 instructinginforming staff on new or revised quality programs or plans, regulatory and accreditation standards, andor performance improvement processes as applicable. (EF) 2.Collaborates in an interdisciplinary manner on hospital-wide patient safety, performance improvement, and data managementanalysis 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) QUALITYSAFETY - 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 carerisk issues including participationfacilitation 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) GROWTHINNOVATION - 15 1.Designs, develops, and implements project plans related to strategic quality and safety initiatives. Manages reporting of these projectsmeasures to internal departmentscommittees andor 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 businessjob duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises. EDUCATION REQUIREMENTS oBachelor of Science or higher degree in Nursing required EXPERIENCE REQUIREMENTS oThree years of experience in a hospital or outpatient clinical role oOne year of experience in a quality management andor 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 SUPPLEMENTAL REQUIREMENTS Work AttireYesNo Uniform No ScrubsNo Business professionalYes 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. Travel 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. Company Profile Houston Methodist Baytown Hospital, located 35 miles southeast of Houston, is the areaaposs 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.