The Quality Safety Strategy Program Manager is responsible for:
• Accreditation and Licensing - The Joint Commission (TJC) and D. C. Department of Health (DC-DOH) activities.
Assist with Commission on Accreditation of Rehabilitation Facilities (CARF) and CMS certification.
• Performance Improvement – Committee Leadership and Support activities; assistance with Board of Directors reports; Quality and Patient Safety activities
• Patient Safety Coordinator
• Family Advocacy in collaboration with Children's National's Ombudsman Team
• Collaboration with Children's Hospital's Risk Management team as point person for Safety Event Reporting
• Policy Management for Children's National Rehabilitation & Specialized Care Center

Minimum Education
Bachelor's Degree (Required)
Master's Degree in Public Health or related field (Preferred)

Minimum Work Experience
3 years of experience in a healthcare environment including leading operational or clinical teams through strategic change or adoption of new initatives (Required)
2 years of experience with The Joint Commission® Hospital standards and survey processes (Preferred)
2 years of experience with DC Health regulations and inspection standards. (Preferred)
Experience leading quality initiatives or performance improvement activities with defined outcomes (Preferred)
Experience with Microsoft Office Solutions including Excel, SharePoint and PowerPoint

Required Licenses and Certifications
Registered Nurse (Preferred)

Job Functions
Essential job duties:

• Accreditation and Licensing – All Submissions, Deadlines and Reporting Activities as Required by TJC and DC – DOH.

• Ongoing front-line oversight of all accreditation updates and regulatory changes with accompanying staff education.

• Coordination of on-site survey activities.

• Performance Improvement –

• a. Team and Committee Leadership in Collaboration with Children's National-Patient Experience Committee; Survey Readiness Team; Patient Safety Team

• b. Team and Committee Meeting Attendance – Hospital Quality Council; Hospital Safety Committee; Patient Care Services Team; Pharmacy & Therapeutics / Medication Safety Committee; Department Managers; Medical Executive Committee, Children's National Accreditation Readiness Team (ART)

• c. Team and Committee Support Activities (I.e. Agenda, Minutes, Reports) – Hospital Quality Council; Hospital Safety Committee; Medical Executive Committee

• d. Board of Directors – Annual PI Plan Approval; Quarterly PI Dashboard; Annual Evaluation of the PI Plan Report; Annual Safety/Risk Plan, Zero Harm Index

• e. FMEAs / RCAs / ACAs/ PI Teams – Facilitator; Recorder

• f. Assists leadership throughout hospital in identifying appropriate Performance Improvement indicators for their areas based on regulatory requirements, past performance in surveys and the identification of opportunities for improvement in their respective areas,

• g. Compiles and submits corrective action plans following regulatory visits in collaboration with managers and directors.

• Patient Safety Coordinator

• a. Through event reporting, identify trends related to Patient Safety issues to present at Patient Safety Committee and in Collaboration with Children's National Patient Safety Committee

• b. Develop a rapport with staff that will allow for reporting of patient safety issues

• c. Collaborate with Patient Safety Team to identify strategies to assess, evaluate and address patient safety issues

• Family Advocate

• a. Check Speak Up Hotline on a routine basis

• b. Assist with identification of complaint vs. grievance

• c. Assist Children's National's Risk and Ombudsman Team with the grievance process

• d. f directed by the Children's National Risk and Ombudsman Team, ensure notifications to families are prepared by management and delivered in appropriate timeframe

• e. In collaboration with Children's National, report complaints and grievances to appropriate committees

• f. Explore methods of getting patient/family feedback through Patient/Family Satisfaction Surveys. Compile feedback and report out to appropriate committees.

• Policy Medical®

• a. HSC Pediatric Center point of contact

• b. Uploads policies to Policy Medical

• Other duties:

• a. For non- clinical areas, has attended training and demonstrates usage of population specific customer service practices.

• b. Maintains skills, regulatory requirements, and credentials needed to perform assigned duties.

• c. Demonstrates full knowledge of current position’s and Department’s relationship to flow of services and care plan of the patient. Demonstrates working knowledge of all other services at the company.

Other job duties:

• May perform other duties in addition to those outlined in this job description.