Description
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 required
**WORK 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 60 days **OR**
RN-Temp - Registered Nurse - Temporary State Licensure within 60 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* No
**TRAVEL****
-**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 Cypress Hospital, scheduled to open in the first quarter of 2025, will be Houston Methodist's ninth hospital and will incorporate the most advanced technology available from the day the doors open. With 100 beds (at our opening; licensed for 276) and a prime location in the heart of the rapidly growing U. S. 290 corridor, the hospital will be equipped with technologically advanced innovations implemented during COVID, many of them designed to make patient communication with physicians, staff and families the ve
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