JOB DESCRIPTION FOR JOB TITLE: - Home | UW Health



|POSITION SPECIFICS |

|Title: Program Manager - AFCH Quality Improvement |Department/Number: Quality Resources - 1015 |

|Reports to: Program Director – UW Health Organizational Performance & |PD Status: Approved |

|Patient Safety | |

|Job Code: 2461 |FLSA Status: Exempt |Bargaining Unit: Non-Rep | |

|Manager Approval Date:       |HR Approval: DPS 7-13 |

|POSITION SUMMARY |

|Under the direction of the Director of Quality and Patient Safety and in direct collaboration with the American Family Children’s Hospital (AFCH) Director of |

|Pediatric Nursing and Patient Care Services, AFCH Vice President, and Medical Director this position is responsible for support and guidance in the development|

|and enhancement of an organized system to monitor, evaluate, and design plans to improve the quality and appropriateness of care delivered at AFCH and areas |

|within UWHC where children are served. The incumbent serves as a change agent to drive improvement activities in real time, and is results and action-oriented |

|with a keen focus on improving patient outcomes with subsequent improvement of operational and financial outcomes. The incumbent advises the clinical and |

|administrative leaders and other staff as indicated regarding effective methods to measure and improve clinical performance, and benchmarks with other |

|pediatric healthcare organizations in the process. Using quality management theory and tools, the incumbent assists in the planning, organizing, coordinating, |

|and facilitating multidisciplinary teams to measurably improve the processes and outcomes of care and service provided to pediatric patients at AFCH/UWHC. The |

|incumbent will perform research and literature reviews, and provide consultation to stakeholders to support the development of quality improvement projects |

|including project design, implementation, and evaluation. The incumbent assists with tracking and reporting those measures to the appropriate committees within|

|AFCH (e.g. AFCH Practice Council, Quality and Coordinating Council, IMOC Unit Committees, and Unit Nursing Councils), and UWHC (i.e. Safety, Satisfaction, and |

|Performance Improvement (SSPI) Committee., and assists with reporting data via applicable scorecards and UW Health Website. |

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|The incumbent staffs the AFCH Medical staff peer review committees (i.e. pediatric, trauma) and in so doing routinely performs chart review and monitors |

|practice activities as it relates to the peer review process. Peer review data are collected and reported in compliance with the hospital medical staff peer |

|review policy for purposes of credentialing and re-appointment. This incumbent also facilitates root cause analysis (RCA) teams and failure modes and effects |

|analyses. |

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|The incumbent provides guidance to clinical staff related to the interpretation and application of standards of care as defined by The Joint Commission (TJC), |

|Centers for Medicare and Medicaid Services (CMS), specialty physician professional organizations (i.e. American Academy of Pediatrics, American College of |

|Surgeons, American Society for Anesthesiologists), children’s healthcare organizations (i.e. Children’s Oncology Group, Children’s Hospital Association, etc…),|

|and other regulatory agencies. The incumbent works collaboratively with AFCH clinical leadership to ensure compliance with these standards. The incumbent |

|maintains strict confidentiality as he/she handles a moderate to high level of complex factors in the assessment of the care delivered. The incumbent works |

|collaboratively with a variety of clinical staff from the multidisciplinary team (i.e. medical, pharmacy, nursing, respiratory staff, etc…) to obtain critical |

|information for the determination of appropriate care. |

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|The Program Manager - AFCH Quality Improvement is expected to be an expert at all aspects of the AFCH/UWHC Quality Improvement function and possesses and |

|applies a broad knowledge of principals, practices, and procedures of the Quality Improvement field to complete assignments. Incumbents at the Senior level are|

|typically responsible for the most complex Quality Improvement Assignments and are able to lead as well as actively participate in significant improvement |

|initiatives. |

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|The Program Manager - AFCH Quality Improvement provides direct supervision to staff for designated registries (i.e. Vermont Oxford, VPS, and others as |

|identified) and works collaboratively with other registry staff that provides information related to care delivered with AFCH patients. In the direct |

|supervisory role the incumbent ensures the data provided by the data abstractors is reliable and that improvement projects generated from the registry is |

|coordinated and is in line with the priorities established by the AFCH clinical and administrative leaders. In the collaborative role, the incumbent |

|communicates with the clinical leaders associated with those registries and ensures the data is being used to improve outcomes and is in keeping with the |

|priorities of AFCH clinical and administrative leaders. |

|MAJOR RESPONSIBILITIES |

|In collaboration with the AFCH clinical and administrative leaders (as identified above) the Program Manager - AFCH Quality Improvement performs the following |

|responsibilities as they relate to the most complex assignments. The incumbent also supervises the activities of the designated registries. |

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|INTEGRATED QUALITY PLAN DEVELOPMENT AND EVALUATION |

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|Compiles, inputs, focuses attention, facilitates development/revision of annual plan for quality, safety, and service for AFCH and areas within AFCH where |

|children are serviced. Makes recommendations for planning based on data such as PSN events, new developments including measures, externally reported data, |

|patterns of clinical practice variation, and regulatory changes. |

|Aligns quality plan with organizational strategies and all regulatory requirements. |

|Partners with AFCH leadership in the implementation of action plans to accomplish quality plan objectives. |

|Provides regular and periodic reports to AFCH leadership per Integrated Plan milestones. |

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|MONITORING AND EVALUATION |

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|Develop, maintain, and manage an organized monitoring and evaluation system (balanced measures of plan goals/progress, core processes) for AFCH; and regularly |

|monitors/reports outcome/progress against plan. |

|Leads development and revision of quality indicators used in monitoring and evaluation. |

|Develop and maintain organized performance data sets for AFCH performance improvement activities for ready report to sponsors and other process stakeholders. |

|Analyzes data and identifies trends for discussion with leadership and recommendations for areas of improvement. |

|Support medical staff peer review monitoring via review of health records using systematic departmental indices and referral of other quality of care concerns.|

|Refer issues related to the quality and safety of patient care to appropriate body. Maintain computerized, physician-specific records of performance and all |

|peer review actions. Submit timely reports of physician activity for re-appointment. Assist the Medical Staff Office with interpretation of performance data. |

|Incorporate/interpret findings of other review committees (e.g, Infection Control, Medical Records, Pharmacy and Therapeutics, Autopsy, etc.) to assigned AFCH |

|quality improvement committees. |

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|PERFORMANCE IMPROVEMENT FACILITATION/CONSULTATION |

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|In collaboration with clinical leaders facilitates literature searches / reviews and authors standards, protocols, policies, and procedures as appropriate to |

|assure that departmental practices reflect best known evidence and comply with relevant regulation. |

|Uses retrievable data (e.g. hospital-wide indicators, department-specific indicators, peer review, financial and other sources) to identify vulnerable |

|processes or under-performing practice patterns or outcomes and to guide and support improvement initiatives. |

|Supports or leads (as delegated) achievement of improved patient, provider, and system outcomes; including facilitation of multidisciplinary performance |

|improvement teams. |

|As appropriate, develops team charter, meeting focus, agendas and relevant meeting materials; conducts background research, including literature searches and |

|interviews; provides consultation to team leaders to enhance effectiveness. |

|Provides just-in-time training of team members in appropriate use of performance improvement tools and approaches. |

|Communicates team progress to sponsors, AFCH and UWHC quality committees, and other stakeholders as appropriate. |

|Facilitates investigation and causal analysis for critical events as assigned, using state of the art RCA, FMEA and other analytical tools and advancing |

|effective corrective actions. |

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|DATA MANAGEMENT, ANALYSIS, TRENDING, AND PRESENTATION |

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|Develop a means to measure the performance and demonstrate improvements in clinical practice across settings. Make information available to prioritize and/or |

|support measurable performance. |

|Develop data collection mechanisms, analyze data in real time from medical charts, computerized decision support systems and self-generated databases created |

|to meet the needs of a particular initiative. |

|Uses systematic processes to routinely verify integrity, accuracy, and relevancy of data and consults experts when assistance is needed. |

|Utilize appropriate statistical approach to measure performance. Collect, organize and format data for presentation. |

|Organizes and analyzes data and presents results to facilitate meaningful interpretation by customers, including value-added recommendations. |

|Uses data to provide consistent performance feedback to Service Line faculty and staff leaders, with special recognition of opportunities for improvement. |

|Work independently or with medical faculty to assist with research applications or manuscripts as needed to support UW Health strategic goals. |

|Provides direct supervision for data abstractors associated with (Vermont Oxford, VPS, and others as indicated) to ensure data is reliable, the abstractors are|

|productive, and outcomes are being reported to the appropriate stakeholders. |

|Collaborates with other registries that abstract data related to the care of children to ensure the outcome data is being assessed and utilized by the |

|appropriate stakeholders to improve outcomes. |

|Ensures the improvement projects related to registry work is in line with the AFCH strategic goals. |

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|AFCH PATIENT SAFETY OFFICER – UNDER THE DIRECTION OF THE UW HEALTH PATIENT SAFETY OFFICER |

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|Collaborates and coordinates with other staff members who have quality and safety responsibilities. |

|Communicate safety policies, theories and strategies and facilitate translation into action |

|Facilitate the planning, management and implementation of patient safety initiatives across AFCH and UWHC areas in which children are served, including TJC |

|National Patient Safety Goals and NQF Safe Practices, among others. |

|Participate in the development and implementation of strategic plans for patient safety and meeting milestones, deadlines, and deliverables that position AFCH |

|as a patient quality and safety leader, including education and communication plans. |

|Responsible for AFCH and UWHC areas in which children are served, Patient Safety Leadership Walk arounds ensuring documentation of identified issues and |

|appropriate follow-up including; feedback to participants, and develop quarterly communications to AFCH Practice Council, AFCH Quality Coordinating Council, |

|UWHC Operations Council, and other leadership committees as appropriate. |

|Scan externally to maintain awareness of new and existing patient safety issues as it relates to the care of children. |

|Provide content expertise in and outside the organization on patient safety improvement strategy and methodology. |

|Support Quality & Safety Director who will represent UW Hospital and Clinics in a variety of internal and external meetings. Outreaches to the UW School of |

|Medicine and Public Health, the Schools of Nursing, and Pharmacy to advance patient safety. |

|Accountable for a comprehensive safety event data collection and management system insuring data reports, analysis; and establish benchmarks and targets as it |

|relates to AFCH. |

|Responsible for building and implementing safety systems and the promotion of the culture of safety within AFCH, paramount foundations for safe operations. |

|Implements and evaluates a regularly scheduled Culture of Safety Survey – frequency to be determined with leadership. |

|Support Quality & Safety Director who is responsible for maintaining clear communication with leadership and governance to communicate relevant patient safety |

|information and lessons learned from the facility which has potential impact beyond a unit/clinic/department/organization. |

|Publish, speak and present results of patient safety work to share knowledge, advance science, spread innovations and promote wider public awareness. |

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|REGULATORY COMPLIANCE OVERSIGHT |

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|Facilitate the development of measurable standards of care and clinical outcomes. |

|Ensure compliance with key state, federal, and select voluntary regulatory / accreditation standards and laws (e.g. TJC, CMS). |

|Document compliance with external review agency standards. |

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|DEVELOPMENT TO ENHANCE ROLE AND CONTRIBUTE TO CUSTOMERS |

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|Represents AFCH in organization and external meetings and agencies. Serves as a liaison between AFCH Risk Management, Patient Relations, Care Management, and |

|other clinical departments to assure timely review of patient care issues. |

|Conducts environmental scanning to benchmark departmental performance, identify high reliability practices, and potentially apply learnings to other clinical |

|groups as appropriate. |

|Assumes personal responsibility to continue professional development via a variety of venues (i.e. research reviews, seminars, grand rounds, etc…). |

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|Other Duties as Assigned |

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|All duties and requirements must be performed consistent with the UWHC Organizational Performance Standards. |

|POSITION REQUIREMENTS |

|Education |Minimum |Bachelors of Science degree in nursing, business, health care or other related field |

| |Preferred |Masters or Doctorate degree |

|Work Experience |Minimum |Three (3) years health care related experience |

| | |Five (5) years of Quality Improvement related experience |

| |Preferred |Professional experience within a children’s hospital |

|Licenses & Certifications |Minimum | |

| |Preferred |RN |

|Required Skills, Knowledge, and Abilities |Leadership skills |

| |Knowledge of TJC standards and regulatory compliance issues including those specifically related |

| |to the care of children and their families |

| |Experience applying quality management/performance improvement and customer service approaches. |

| |Demonstrated capabilities with Windows based software applications including word processing, |

| |spreadsheets and database. Requires some experience with database analysis. |

| |Knowledge of disease classification systems such as ICD9-CM and professional billing |

| |classifications such as CPT-4. |

| |Excellent verbal and written communication skills. |

|AGE – SPECIFIC COMPETENCY |

|Identify age-specific competencies for direct and indirect patient care providers who regularly assess, manage and treat patients. |

|Instructions: Indicate the age groups of patients served either by direct or indirect patient care by checking the appropriate boxes below. Next, |

|x |Infants (Birth – 11 months) |x |Adolescent (13 – 19 years) |

|x |Toddlers (1 – 3 years) |x |Young Adult (20 – 40 years) |

|x |Preschool (4 – 5 years) |x |Middle Adult (41 – 65 years) |

|x |School Age (6 – 12 years) |x |Older Adult (Over 65 years) |

|Job Function |

|Review the employee’s job description, and identify each essential function that is performed differently based on the age group of the patient. |

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|PHYSICAL REQUIREMENTS |

|Indicate the appropriate physical requirements of this job in the course of a shift. Note: reasonable accommodations may be made available for individuals |

|with disabilities to perform the essential functions of this position. |

|Physical Demand Level |Occasional |Frequent |Constant |

| |Up to 33% of the time |34%-66% of the time |67%-100% of the time |

|X |Sedentary: Ability to lift up to 10 pounds maximum|Up to 10# |Negligible |Negligible |

| |and occasionally lifting and/or carrying such | | | |

| |articles as dockets, ledgers and small tools. | | | |

| |Although a sedentary job is defined as one, which | | | |

| |involves sitting, a certain amount of walking and | | | |

| |standing is often necessary in carrying out job | | | |

| |duties. Jobs are sedentary if walking and | | | |

| |standing are required only occasionally and other | | | |

| |sedentary criteria are met. | | | |

| |Light: Ability to lift up to 20 pounds maximum |Up to 20# |Up to 10# or requires |Negligible or constant push/pull |

| |with frequent lifting and/or carrying of objects | |significant walking or |of items of negligible weight |

| |weighing up to 10 pounds. Even though the weight | |standing, or requires | |

| |lifted may only be a negligible amount, a job is | |pushing/pulling of arm/leg | |

| |in this category when it requires walking or | |controls | |

| |standing to a significant degree. | | | |

| |Medium: Ability to lift up to 50 pounds maximum |20-50# |10-25# |Negligible-10# |

| |with frequent lifting/and or carrying objects | | | |

| |weighing up to 25 pounds. | | | |

|List any other physical requirements or bona fide | |

|occupational qualifications: | |

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