Minimum Qualifications:

Bachelor degree in Nursing, Healthcare Administration or related clinical program field

Eight (8) years of experience directly related to quality/performance improvement functions within a healthcare setting:

LICENSES, REGISTRATIONS OR CERTIFICATIONS

Required:

Valid state of Texas Professional Nursing (RN) license or clinical program professional registration

Preferred:

Six Sigma Green Belt or Certified Professional in Healthcare Quality (CPHQ) certification

JOB DESCRIPTION

Scope: The QAPI Manager, Clinical Services is a designated member of the clinical team and is responsible, under the guidance of the Department Administrator, for overseeing and continually evaluating the effectiveness of the operational components of the QAPI plan including metric development and selection, data capture, data analysis, opportunity identification, and ongoing operational survey readiness for all regulatory bodies. They are responsible for independently implementing initiatives aimed at improving quality outcomes.

Function: This individual is tasked with developing and maintaining the QAPI program and an educational framework that ensures all clinical programs and other hospital department staff have knowledge of new and existing regulatory requirements related to quality and patient safety. They will serve as the key liaison during survey activities. They will also serves as advisor and subject matter expert in Joint Commission, CMS, Texas Department of Health and Services and other regulatory agency standards and policies. The manager oversees staff that aid in developing and implementing new programs aimed at improving or maintaining departmental effectiveness and efficiency, and reviews identified opportunities for improvement. This individual supervises designated support staff.

ESSENTIAL JOB FUNCTIONS

Quality:

• Oversees all collaboration with medical staff and operational leadership to facilitate evidence-based quality and patient safety initiatives; engages associates at all levels in continuous pursuit of improvement opportunities.
• Provides project management and facilitation, as well as, oversight and support for key functions and processes for the systematic, coordinated, and continuous improvement of patient care delivery.
• Ensures quality and performance improvement initiatives are aligned with regulatory standards and healthcare best practices and reporting of quality outcomes and performance improvement initiatives.

• Ensures the integration of aggregate data into performance improvement planning and problem resolution.

• Monitors the use of statistical process tools and process improvement methodologies used to ensure continuous improvement in patient care and outcomes.
• Evaluates the relationship of quality and performance improvement initiatives with patient outcomes to determine if desired results have been achieved or sustained.
• Compares performance data and outcomes with authoritative external sources and benchmarks.
• Organizes and leads relevant task forces or work groups, for reviewing evidenced based literature/benchmarks, and suggesting revisions/additions to the indicators for monitoring and evaluation of quality, regulatory and accreditation goals and objectives
• Prioritizes and sets strategic direction for improvement efforts based on alignment with health system and transplant program goals, as well as, clinical performance with regard to patient safety and pro-active reduction of risk.
• Directs communication with hospital clinical risk management to identify adverse events, communication of the events to the transplant program leadership and staff, and provide oversight during the root cause analysis and improvement remediation processes related to these events.

Regulatory Readiness:

• Responsible for independently developing and implementing initiatives supporting compliance with accreditation, licensure and regulatory standards for the service line program. Establishes and implements programs to assess state of readiness for surveys, focusing upon continual preparation.
• Monitors internal compliance with survey readiness program and presents findings and recommendations for improvement.
• Key liaison during survey visits/activities and post-survey follow-up activities. Prepares and coordinates responses to regulatory agencies on corrective action plans, inquiries, and other requested information.
• Guides and coordinates policy/practice review to ensure alignment with regulatory and accrediting standards, best practices, and evidence-based practice.
• Continually reviews and monitors Joint Commission data and changes in interpretations; communicates new or modified regulatory standards as appropriate; makes recommendations to ensure compliance.
• Serves as the subject matter expert and resource for Joint Commission accreditation standards and accreditation requirements specific to transplant programs.

Management and Consultative:

• Serves as program management representative in system or facility performance improvement, regulatory readiness and/or quality teams. Builds mutual trust and encourages respect and cooperation among team members to support movement from current state of practice to desired state of practice, address and mutually resolve issues.
• Supervises support staff performance and clarifies work expectations, and defines goalsetting; promotes and mentors cooperation among individuals and groups.
• Develops and implements processes through orientation, training and education to ensure that the competence of staff members is assessed, maintained, improved and demonstrated throughout their employment.

Marginal or Periodic Functions:

• Performs related duties as assigned in alignment with business needs

KNOWLEDGE/SKILLS/ABILITIES

• Sound working knowledge of concepts, practices, and procedures related to quality improvement functions specific to clinical program supporting.
• Demonstrated knowledge and expertise in the application of advanced quality tools and methodologies.
• Strong facilitation skills with proven ability to plan, implement, coach and assist others in performance improvement measures.
• Strong technical ability in basic business software and power automation such as PowerBI, PowerApps, Excel, PowerPoint, Word. Technical skill in database software such as Access and statistical analysis software such as Minitab, STATA and SPSS.
• Experience with Joint Commission, state licensure and CMS Conditions of Participation survey process and regulatory compliance.
• Demonstrated capability in facilitating a collaborative approach to compliance with regulatory standards.
• Ability to consult and negotiate in situations that are controversial and/or sensitive that result in mutual decisions. Ability to exercise discretion in what and how to communicate.
• Ability to read and interpret complex statutes and regulations and apply knowledge to manage compliance risk exposure.
• Demonstrated ability to manage by influence in a consultative role that does not have direct authority.
• Strong professional, organizational, and interpersonal skills required for effective and creative leadership in working with all levels of the organization.
• Ability to lead and motivate individuals and groups toward the accomplishment of organizational goals.
• Possesses good analytical and problem solving skills. Demonstrates a high level of organizational skills to establish and manage priorities and maintain follow-up.

Salary

Commensurate with experience $92,080 - 119,700.

Equal Employment Opportunity

UTMB Health strives to provide equal opportunity employment without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, genetic information, disability, veteran status, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. As a Federal Contractor, UTMB Health takes affirmative action to hire and advance protected veterans and individuals with disabilities.