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.

　　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 hospital-wide 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 all-inclusive; 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 requiredWORK 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 90 days or

　　RN-Temp - Registered Nurse - Temporary State Licensure within 90 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 on-going 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

　　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

　　ON-CALL*

　　*Note that employees may be required to be on-call during emergencies (ie. DIsaster, Severe Weather Events, etc) regardless of selection below.

　　On Call* NoTRAVEL**

　　Travel specifications may vary by department

　　May require travel within the Houston Metropolitan area Yes

　　May require travel outside Houston Metropolitan area Yes

　　Company Profile:

　　Houston Methodist West Hospital is committed to leading medicine in West Houston, Katy and surrounding communities by delivering the Houston Methodist standard of exceptional safety, quality, personalized service and innovation. The growing campus offers more than 200 beds, 22 operating rooms and more than 1,900 employees. Originally opened in 2010, the campus is expanding as part of the master plan, adding additional inpatient beds and a third medical office building to the campus by late 2023.

　　Houston Methodist is an equal opportunity employer inclusive of women, minorities, disabled persons and veterans.

　　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.

　　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.