Position Summary:

The Quality Improvement Specialist will have the primary responsibility of coordinating key quality improvement (QI) activities and projects for the UTHealth Houston Behavioral Sciences Campus. Under the direction of the Director, this position will coordinate the quality improvement, patient safety and clinical risk management program for the campus.

Location: Dunn Behavioral Sciences Center/HCPC at UTHealth Houston

Dept.: BSC Quality

Status: Full-Time

FLSA: Exempt

Position Key Accountabilities:

• Prepares clinical performance improvement initiatives and outcomes reports for the administration and other governing bodies.
• Maintains continued Regulatory survey readiness with regards to CMS, State and The Joint Commission Standards. Conducts and assists in The Joint Commission mock surveys, performs analysis of survey outcomes and reports findings and develops appropriate action plans in coordination with key clinical managers and administration.
• Investigate, aggregate and evaluate defined quality metrics for UTHealth John S. Dunn Behavioral Sciences Center (HCPC and DCB Buildings). Generate program reports for analysis. Obtains quality metrics from the Electronic Health Records (Epic).
• Identify key performance metrics in various areas; monitor and report on metrics as necessary.
• Provides quality assurance / improvement technical assistance and subject matter expertise with local process improvement initiatives.
• Provides formal input towards the development of action plans or other follow up activities related to data collection activities.
• Coordinates implementation of training programs and delivers training as assigned. Develops and implements program tools to support clinical practice transformation goals. Coordinates with other entities to ensure consistency of documentation and other tools needed to successfully meet program objectives.
• Monitors quality improvement goals and tracks outcomes and measurements.
• Assist in the development, data retrieval, and analysis of medical staff quality improvement studies and medical staff indicator results.
• Performs other duties as assigned.

Certification/Skills:

• Superior written and verbal communication skills.
• Expertise in Microsoft Office suite of applications and healthcare quality data analysis.
• Registered Nurse (RN) State Licensure or Nurse Licensure Compact (NLC) by Texas Board of Nursing (BON) required
• Lean Six Sigma Black Belt (LSSBB) by American Society for Quality (ASQ), Council for Six Sigma Certification (CSSC), International Association for Six Sigma Certification (IASSC), or Lean Six Sigma Institute (LSSI) preferred
• Certified Professional in Healthcare Quality (CPHQ) by National Association for Healthcare Quality (NAHQ) preferred

Minimum Education:
Bachelor's Degree in Nursing from an accredited nursing school with one year nursing experience required Associate's Degree in Nursing from an accredited nursing school with three years nursing experience required Nursing Diploma (3 year program) and two years nursing experience required Master's Degree preferred
Minimum Experience:
Years of experience varies based on education level required Experience in acute care hospital (behavioral health ) quality and/or process improvement training/education (Six Sigma, LEAN, Robust Process Improvement) preferred
Physical Requirements:
Exerts up to 20 pounds of force occasionally and/or up to 10 pounds frequently and/or a negligible amount constantly to move objects.
Security Sensitive:
This position is a security-sensitive position pursuant to Texas Education Code §51.215 and Texas Government Code §411.094. To the extent that a position requires the holder to research, work on, or have access to critical infrastructure as defined in Texas Business and Commerce Code §117.001(2), the ability to maintain the security or integrity of the infrastructure is a minimum qualification to be hired for and to continue to be employed in that position. Personnel in such positions, and similarly situated state contractors, will be routinely reviewed to determine whether things such as criminal history or continuous connections to the government or political apparatus of a foreign adversary might prevent the applicant, employee, or contractor from being able to maintain the security or integrity of the infrastructure. A foreign adversary is a nation listed in 15 C.F.R. §791.4.
Residency Requirement:

Employees must permanently reside and work in the State of Texas.