JOB SUMMARY:

To serve as a facilitator of quality assessment activities to one or more clinical departments. Coordinates reporting from hospital department’s quality management and improvement programs, ensuring compliance with the Hospital Performance Improvement Plan, the individual Quality Improvement Plans for hospital departments and Joint Commission and Centers for Medicare and Medicaid Services (CMS) requirements.

ESSENTIAL JOB FUNCTIONS:

• Organizes quality management activities for one or more clinical and hospital departments
• In collaboration with clinical staff and leadership, participates in the monitoring, reporting, and improvement activities related to clinical guidelines, healthcare quality/safety initiatives, accreditation and regulatory requirements.
• Research and identify process improvements and help set standards and define best practices for assigned departments.
• Organizes, attends and facilitates departmental quality management meetings and attends Mortality and Morbidity conferences.
• Uses data to assist departments in making process changes.
• Educates and assists clinical departments in developing appropriate ongoing quality management/monitoring programs.
• Ensures compliance of areas of responsibility with CMS and Joint Commission requirements.
• Facilitates continuous process improvement teams using the Focus Analyze Develop and Execute (FADE) methodology
• Facilitates proactive and reactive patient safety activities including Root Cause Analyses (RCA), Failure Mode Effects Analyses (FMEA) and Sentinel Event Alerts in regard to the facilitation process, planning, implementation and evaluation of effectiveness of process changes.

MARGINAL OR PERIODIC JOB FUNCTIONS:

• Executes position responsibilities that demonstrate leadership, experience, and creative approaches to management of developmental needs that contribute to the enhancement of patient care.
• Regularly communicates PI and quality/safety activities to leadership and QM staff. 
• Adheres to internal controls and reporting structure.

REQUIRED EDUCATION / EXPERIENCE:

• Bachelor’s degree in Nursing, Business Management, Industrial Engineering, or Organizational Development or Registered Record Administrator (RRA)
• Four years clinical experience which includes one year experience in quality management and process improvement or comparable experience.

EQUIPMENT:

Standard office equipment.

WORKING ENVIRONMENT/LOCATION OF POSITION:

Standard hospital, clinical, laboratory and/or office environments. 

OTHER:

Specific job requirements or physical location of some positions allocated to this classification, may render this position security sensitive, and thereby subject to the provisions of Section 51.215, Texas Education Code.

ANY QUALIFICATIONS TO BE CONSIDERED AS EQUIVALENTS IN LIEU OF STATED MINIMUMS REQUIRE THE PRIOR APPROVAL OF THE CHIEF HUMAN RESOURCES OFFICER. 

THE UNIVERSITY OF TEXAS MEDICAL BRANCH AT GALVESTON IS AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION UNIVERSITY