The activities in this position support the overall Quality Management and Patient Safety System at Howard University Hospital. Performance Improvement activities are executed in four domains: Patient Safety, Quality Management, Regulatory Compliance, and Document Control. While a staff may be assigned one or more domains, training and proficiency across all domains are required. This position requires personnel to maintain a high degree of confidentiality and security of information that associates are exposed to during the normal course of performing job functions. The job functions for this position are subject to change and evolve as external regulations evolve and change.
There are no direct reports to this position.
NATURE AND SCOPE:
This is a highly visible position. Interactions include but are not limited to Executive Leadership, Directors Forum, Medical Staff, House Staff, Hospital Associates, Consultants, External Regulatory Agencies (local and national), Federal Agencies, vendors, Howard University staff and students, trade organizations, patients, and families.
Patient Safety Domain
Responsible for maintaining high level of confidentiality and security of information related to patient safety events
Administrative oversight of the incident reporting system
Responsible for daily Quality Manager Review and monitoring of patient safety events entered into the electronic incident reporting system.
Responsible for following up with department leaders to ensure that steps have been taken to decrease the likelihood of the event recurring
Responsible for completing the event in the incident reporting system
Assign a status to the event designating whether the event will be sent to the Patient Safety Organization (PSO).
Generation and dissemination of trend reports to stakeholders
Responsible for immediately notifying Director of Quality Management of events that meet organization definition of a sentinel event.
Conduct a quality of care review when indicated
Responsible leading activities related to conducting Root Cause Analyses
Use data to inform decisions related to the selection of processes to perform Failure Mode Effect and Criticality Analyses
Conducts Failure Mode Effect and Criticality Analyses
Quality Management Domain
Responsible for maintaining high level of confidentiality and security of patient information
Generates and upload weekly XML files for inpatient and outpatient quality indicators to the Core Measure Vendor
Responsible for ongoing abstractions of chart abstracted core measures
Provide timely feedback to stakeholders
Works with stakeholders to improve performance
Generates and disseminates reports to stakeholders
Responsible for timely abstraction that meets deadlines set by Core Measure Vendor, The Joint Commission, and The Centers for Medicare and Medicaid Services
Enters web-based measures into the Secure Quality Net Site
Conduct quality review of cases coded as hospital acquired condition or hospital acquired infections
Facilitate and/or serve on performance improvement teams and committees
Assist stakeholders with improvement activities related to eCQM (electronic Clinical Quality Measures
Maintain current knowledge of quality measure specification and reporting requirements
Regulatory Compliance Domain
Responsible for maintaining high level of confidentiality and security of organizational regulatory information
Responsible for ongoing regulatory readiness for The Joint Commission (TJC) Triennial Survey and Annual Licensure Survey by the District of Columbia Department of Health (DCDOH)
Participates in the TJC Focused Survey Assessment annually
Maintains TJC AMP (Accreditation Manager Plus®) in a current status to facilitate Periodic Performance Review (PPR)
Participates in onsite visits by regulatory agencies including “for cause visits” and “complaint investigations”
Conducts audits as assigned and inputs information into the AMP.
Generates, analyze, and interprets compliance reports related to regulatory readiness and audits and disseminates reports to stakeholders in a timely manner.
Works with department leaders to improve compliance and performance.
Maintain current knowledge regulatory rules and requirements.
Document Control Domain
Responsible for the administrative oversight of the electronic policy management system to include reviewing policy for formatting, uploading documents, setting up approval groups and approval templates.
Ensures policies are reviewed at the frequency designated by its document type (e.g. annually, biannually, triennially)
Creates system reports for active policies, expired policies and policies in the approval process
Ensures all policies adhere to the approval process outlined in the policy that governs the development and implementation of policies.
Archives expired policies and ensure only the current policy is accessible by the end-uses
Assumes other duties and responsibilities that are related and appropriate to the position and area. The above responsibilities are a general description of the level and nature of the work assigned to this classification and are not to be considered as all-inclusive.
Achieves appropriate Hospital performance, quality, and productivity standards as established.
Promotes adherence to the Health Sciences Compliance Program, the Howard University Code of Ethics and the Health Sciences Standards of Conduct.
Attends annual and periodic mandatory Compliance Program training including the Health Insurance Portability and Accountability Act (HIPAA) Privacy training.
Participates in activities that promote adherence to federal healthcare program requirements.
Actively participates in Health Sciences Compliance Program activities.
Adheres to the requirements of the HIPAA Privacy Policies and Procedures.
Maintains confidentiality of patients, families, and staff.
Provides and assures patient centered, cost efficient, safe, culturally competent, linguistically sensitive and quality care by adhering to evidence based practice.
Knowledge of performance improvement methodologies, safety and reliability science
Skilled in communicating effectively, facilitating group processes and training staff, preparing data analysis
Ability to establish and maintain effective and productive working relationship with all employees, public and private organizations, and regulatory agencies
Ability to work under pressure and to maintain efficiency and composure
Exceptional customer service and interpersonal skills
Proficiency in planning, coordinating and implementing patient and staff safety procedures
Talent for leading and facilitating group and team meetings
Proficient in Microsoft Word, Excel, PowerPoint, and Visio
Competence in both oral and written English.
Ability to establish and maintain effective and harmonious work relationships with staff, physicians, Hospital and University officials, and the general public.
Bachelor of Science Degree in Nursing
Current District of Columbia license to practice as a Registered Nurse or be eligible for endorsement
2-3 years Clinical experience required. 2 years’ experience in patient safety and quality preferred
Internal Candidates Only: LPN with at least 10 years clinical experience and 3 years’ experience in patient safety and quality may be considered. Current District of Columbia license to practice as a Licensed Practical Nurse
Formal training in performance improvement methodologies and patient safety required or obtained within 18 months of starting this position. Formal training may take the form of successful completion of IHI Open School Patient Safety and Quality Modules, National Association of Healthcare Quality certification program for healthcare quality professionals, NPSF certification in patient safety or other nationally recognized comparable training in performance improvement and patient safety.
Howard University Hospital (HUH) is a private, non- profit institution recognized for its ground breaking research and teaching programs. HUH has a rich tradition of leadership and service dating back to 1862. Over the course of its 145 year history of providing the finest primary, secondary, and tertiary health care services, HUH has become one of the most comprehensive health care facilities in ...the Washington, DC metropolitan area and designated a DC Level 1 Trauma Center.
We offer competitive pay, a 403-B Retirement Savings Plan with full vesting on Day 1, comprehensive medical and dental plans, prescription drug benefits, pet insurance, tuition remission for employees and dependents, and more!