Facility Healthcare Program Manager (O-5 Billet) Non-Supervisory

Job TitleDUTIES AND RESPONSIBILITIES: AdministrationWorks collaboratively with the health services administrator as the subject matter expert and key advisor in the day-to-day management, development, implementation and monitoring of the following IHSC programs of responsibility: accreditation readiness and standards compliance, risk management, and quality improvement.Serves as a key member of IHSC national risk management and quality improvement program initiatives, not limited to attending regional/national meetings.Monitors, reviews, coordinates, and ensures complete and timely reporting of accreditation readiness and standards compliance, risk management, and quality improvement activities. Conducts data/trend analysis and implement improvement strategies establishing timeframes for continued monitoring concerning all programs of responsibility.Secures and maintains all files and information concerning all programs of responsibility in accordance with all established policies, procedures, and regulations.Develops and maintains accreditation readiness and standards compliance; risk management; quality improvement; infection control; occupational health; environmental health, safety and security; and all hazards emergency preparedness and response local operating procedures as applicable; forwards revisions and updates to HSA for approval.Ensures accreditation readiness and standards compliance; risk management; quality improvement; infection control; occupational health; environmental health, safety and security; and all hazards emergency preparedness and response standards, including updates on national and local policies and procedures, are disseminated appropriately to staff in a timely manner.Regularly coordinates efforts with FHSO, FTO, and IPO.Provides policy, records, or other documentation concerning all programs of responsibility ae required by investigators.Serves as federal fit tester conducting fit testing for federal staff. Ensures all staff meets annual fit testing requirement.May be asked to perform duties of the FHSO programs of responsibility: infection control; occupational health; environmental health, safety and security; and all hazards emergency preparedness and response when needed.May be asked to serve as an acting HSA or AHSA when needed.Travel required up to 25% as directed by the chief of Health Operations Unit.AccreditationMonitors and reviews established performance indicators for compliance with national IHSC policies and applicable standards (ACA, NCCHC, PBNDS, and/or FRS).Collaborates with the HSA and AHSA in performing assessments of the health unit for accreditation under the appropriate standards and ensures the preparation of the health unit for any accreditation the facility undergoes.Prepares the facility for accreditation/re-accreditation audits by reviewing processes, updating policy, training staff, and building folders for audit preparation, and record keeping for future re-accreditation audits.Ensures compliance standards, including updates on national and local policies and procedures, are disseminated appropriately to staff in a timely manner.Develops recommendations for improvements and success action plans if deficiencies are recognized during accreditation audits and health systems assessments.Participates in the Quality Review Process to include performing self-assessments and pre-audit reviews and observations.Serves as liaison between investigators and facility staff and arranges interviews. Provides policy, records, or other documentation required by investigator and prepares responses to action items in coordination with FHSO, FTO, and IPO.Risk ManagementProvides leadership and oversight of the local risk management program including develop, coordinate, implement, and monitor associated tasks and duties.Assists HSA and AHSA with the investigation of incident reports and adverse events (i.e. root cause analysis, mortality reviews, etc.).Conducts data/trend analysis, develops action plans, implements improvement strategies establishing timeframes for continued monitoring, monitors effectiveness of change, and modifies action plans as needed to yield positive outcomes.Prepares facility responses to correct the identified process issues and reporting findings/recommendations in writing through established chains of communication within specified timeframes. Obtains HSA and AHSA approval prior to submission.