Assistant Director Quality and Performance Improvement

Location: Washington, DC
Date Posted: 05-03-2018
In conjunction with the Director of Quality & Performance Improvement, the Assistant Director of Quality & Performance Improvement responsible for managing the Quality Improvement and Compliance programs at Howard University Hospital. Maintains compliance with the Standards as outlined by The Joint Commission on Accreditation of Healthcare Organizations (TJC) and other regulatory agency’s rules and regulations, such as the Department of Health and CMS. Responsible for the implementation and maintenance of the hospital’s compliance program, ensuring that the Compliance Program effectively detects and prevents violation of federal, state, and contractual law and ethics. 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. This job requires a high level of ability to work independently.
Performance Improvement Advisors
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.
  • Assists in the development of clinical departmental and interdisciplinary Quality Improvement Teams to establish, measure, and report QI and Performance priorities. Assists quality improvement teams in identifying, planning, and executing quality improvement activities.
  • Coordinates, manage, and monitor all survey readiness activities. Monitors organizational compliance with Federal, State and voluntary standards.  Provide assistance as needed in interactions with onsite surveys, inspections and investigations from any/all federal, state and local regulatory authorities.
  • Assist Director in the organization in integration of new standards and requirements.
  • Conducting, assisting, and following up on tracers.
  • Plan and manage mock surveys and follow up.
  • Oversee and perform the collecting, analyzing and preparing of data reports for performance improvement and safety related activities across the hospital. Effectively analyzes data and information to successfully formulate strategies to ensure regulatory readiness and quality outcomes.
  • Monitors problems, associated quality and safety concerns, and complaint reports to identify needs for improvement; implements corrective actions and monitors.
  • Monitors key quality indicators monthly to detect problems and opportunities for improvement.
  • Oversees incident reporting system and sentinel event reporting. Reviews, evaluates, and investigates patient safety events reported through the event reporting System. Conducts root-cause-analysis as required.
  • Maintain hospital compliance with all required external reporting.
  • Represent the Quality Management Department on hospital committees as assigned.
  • Maintains and improves knowledge base of regulations and quality improvement tools and techniques
  • Manage the team of Performance Improvement Advisors to include hiring, training, coaching, completing perform evaluations and provide feedback, and counsels or disciplines as required.
  • 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.
  • 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. 
  • 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.
  • Bachelor of Science Degree in Nursing or other healthcare discipline, Master’s Degree preferred.
  • 3+ years of experience in patient safety, quality and regulatory matters
  • CPHQ and CPPS or obtained within 12 months of starting this position.
  • 5+ years Clinical experience required. 
  • Minimum of two years of supervisory and/or management experience.
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.

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