BASIC FUNCTION:
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.
 
DIMENSIONS:
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.
 
PRINCIPAL ACCOUNTABILITIES:
 
Patient Safety Domain
Under the direction of the Director and/or Assistant Director: 

• 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
Under the direction of the Director and/or Assistant Director:

• 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
Under the direction of the Director and/or Assistant Director:

• 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
Under the direction of the Director and/or Assistant Director:

• 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.

ORGANIZATIONAL EXPECTATIONS:
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.
 
CORE COMPETENCIES:

•  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.

 
CARES CRITERIA:
Must demonstrate collaboration; accountability; respect; excellence; and service.
 
Works with team members and peers in and outside of their immediate work group to create an exceptional experience for patients, students and other visitors; looks for ways to achieve departmental/institutional results by partnering.
 
Accepts responsibility for his/her actions to provide health care and or ancillary functions in a highly efficient and compassionate manner.  The employee must function as a Steward (Have Ownership) of the Howard values that foster a commitment to improving the patient and student experience, organizational efficiency and the environment.
 
Embraces diversity; cares holistically for those we serve; treats all as we would like to be treated; manages the patient’s right to privacy with meticulous care 100% of the time and keeps patient and proprietary information about the institution confidential.
 
Anticipates the patient’s and student’s needs, presents as a model representative of the institution and maintains high standards of care while striving to improve performance and create exceptional experiences for our customers.
 
Behaves in a friendly, resourceful and professional manner towards all they encounter; treats patients, students and visitors in the same way that they would want their family members or themselves to be treated.
 
MINIMUM REQUIREMENTS:
 Bachelor of Science Degree in Nursing or other healthcare related degree. 

• Two (2) years of related experience in nursing, quality improvement, or patient safety in a healthcare environment required.
• In lieu of a healthcare-related degree a minimum of six (6) years of experience in quality or patient safety in a healthcare environment is required (or any combination of education and experience that will provide the candidate the necessary knowledge, skill, and abilities to be able to perform the functions of the position proficiently).
• 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.

 
Must be able to stand, walk, sit, lift, climb, balance, stoop, kneel, crouch, crawl, bend, pull, push, reach, handle, write, type, file, speak, hear, see (depth perception and color vision), calculate, compare, edit, evaluate, interpret, and organize for extended periods of time.