Clinical Quality & Performance Improvement Lead

At Houston Methodist, the Quality Outcomes Specialist position is responsible for assessing and facilitating clinical systems and/or processes to ensure that care delivered is safe, effective, patient-centered, timely, efficient and equitable. This position identifies outcomes variances, taking initiative for timely resolution of potential concerns, and utilizes ability to synthesize an analysis of complex systems, developing and implementing solutions to improve complex processes and goals. Other responsibilities include supporting and promoting the organization-wide clinical performance improvement/patient safety program and culture; and serving as department resource for areas of expertise, sharing knowledge, effective tools and educational materials as appropriate.

FLSA STATUS

Exempt

QUALIFICATIONS

EDUCATION

Bachelor’s degree in nursing, allied health, healthcare administration, business administration or a clinical discipline required Bachelor's degree in is nursing preferred Master’s degree preferred

EXPERIENCE

Four years of experience in clinical care activities in a hospital setting Two years of experience in Hospital Quality Improvement, Case Management or Utilization Management role preferred Two years of leadership experience preferred

LICENSES AND CERTIFICATIONS

CPHQ - Certified Professional in Healthcare Quality (NAHQ) CPSO - Certified Patient Safety Officer (IBFCSM) CPPS - Certified Professional in Patient Safety (IHI) RN - Registered Nurse - Texas State Licensure Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency)

PREFERRED

CPHQ - Certified Professional in Healthcare Quality (NAHQ) CPSO - Certified Patient Safety Officer (IBFCSM) CPPS - Certified Professional in Patient Safety (IHI) RN - Registered Nurse - Texas State Licensure Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency)

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 co-workers in a manner consistent with a customer service focus and application of positive language principles Demonstrates knowledge and application of process improvement tools and techniques (statistical process control tools and team tools) Demonstrates knowledge of regulatory and accrediting standards as they apply to performance improvement Skill in developing and maintaining interpersonal relationships with a wide variety of healthcare professionals and hospital leadership Ability to define problems, collect data, establish facts and draw valid conclusions and evidence performance improvement via measurable results Ability to enter and abstract data using personal computer, as well as the ability to utilize data to facilitate the improvement and change in processes Computer skills to include Excel, Word, and PowerPoint Ability to facilitate performance improvement teams, present data and promote a collaborative approach toward goal achievement Ability to work independently and interdependently Presentation skills and expertise in designing and implementing teams/educational offerings related to clinical quality

PEOPLE ESSENTIAL FUNCTIONS

Leads facility partners to bring expert assessment and problem‑solving skills to ensure reliable, safe systems of care for all patients. Develops and maintains positive working relationships with leadership, physicians, colleagues and peers and works collaboratively to achieve desired outcomes. Collaborates and effectively communicates and drives culture of safety and high‑reliability initiatives; partners with leadership and clinicians to implement improvements. Increases patient safety and evidence‑based practice awareness and practice among clinicians and staff through mentoring and education. Manages project and process improvement expectations to stakeholders, sponsors and others advising them on project progress, potential issues, obstacles, conflicts or challenges.

SERVICE ESSENTIAL FUNCTIONS

Serves as a key quality contact with leadership, managers and staff responsible for the execution of corrective actions initiatives/projects and compliance with customer requirements. Supports leadership with the development and implementation of quality improvement and patient safety process changes. Makes recommendations for unit‑based process change activities. Evaluates the effectiveness of process change initiatives.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

Maintains all programs to ensure compliance to accreditation standards and regulatory agency requirements. Conducts record review for performance improvement, peer review, patient safety, risk management and other projects. Facilitates and leads process and performance improvement teams and initiatives. Participates in and facilitates unit‑based and departmental process change activities. Evaluates the effectiveness and sustainability of process change initiatives and makes changes as necessary to achieve goals. Tracks, analyzes, and uses data for trending and develops appropriate action plans and strategies in collaboration with clinicians and leadership. Conducts record review for performance improvement, peer review, patient safety, risk management and other projects. Abstracts pertinent information and enters into department databases using standardized methods and processes to maintain data integrity. Routinely performs discrepancy management activities to maintain data integrity. Presents meaningful reports and analysis with measurement description, statistical information, and benchmarking information. Creates and presents executive summaries as needed to various audiences to drive change. 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 system's design to hardwire patient safety processes. Focuses on implementing and reinforcing principles that support a high‑reliability organization. Contributes to the continued improvement of patient safety practices, employs evidence‑based practice and researches high‑reliability practices through national Patient Safety Organizations (e.g., Agency for Healthcare Research and Quality (AHRQ), National Patient Safety Foundation (NPSF), Institute for Healthcare Improvement (IHI), National Quality Forum (NQF)). Facilitates systems’ design to hardwire patient safety processes.

FINANCE ESSENTIAL FUNCTIONS

Utilizes efficient and cost‑effective work practices with department resource and supplies; provides recommendations to reduce expenses. Facilitates performance improvement projects/initiatives to improve outcomes, ultimately impacting hospital finances.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

Identifies and recommends opportunities for improvement in accordance with hospital leadership. Analyzes and assesses present and future needs, trends, challenges, and opportunities related to hospital processes and operations. Communicates innovative and best practices to hospital leadership and clinicians. Identifies opportunities to align policy and procedure with regulatory/accreditation requirements.

SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE

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

ON‑CALL

Note that employees may be required to be on-call during emergencies (e.g., 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: No Houston Methodist is an Equal Opportunity Employer. #J-18808-Ljbffr Houston Methodist