Professional Practice Evaluation Program Manager - Quality Improvement (1.0 FTE, Days)
Stanford Children's Health - Lucile Packard Children's Hospital
Location: Palo Alto, California
Internal Number: 10200294
1.0 FTE, 8 Hour Day Shift
At Stanford Children's Health, we know world-renowned care begins with world-class caring. That's why we combine advanced technologies and breakthrough discoveries with family-centered care. It's why we provide our caregivers with continuing education and state-of-the-art facilities, like the newly remodeled Lucile Packard Children's Hospital Stanford. And it's why we need caring, committed people on our team - like you. Join us on our mission to heal humanity, one child and family at a time.
This paragraph summarizes the general nature, level and purpose of the job.
The Professional Practice Evaluation Program Manager facilitates the process for Medical Staff Professional Practice Evaluation at a division/departmental/service line level and integrates findings into the Hospital wide Performance Improvement Program. He/she facilitates compliance with Medical Staff standards as required by regulatory agencies.
The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities. Employees may also perform other duties as assigned.
Employees must abide by all Joint Commission Requirements including but not limited to sensitivity to cultural diversity, patient care, patient rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings.
Must perform all duties and responsibilities in accordance with the Service Standards of the Hospital(s).
Acts as a liaison to the Patient Safety, Medical Staff Office and Risk Management Departments. Communicates information that is relevant to potential or actual legal proceedings.
Assures that communication of information is disseminated to appropriate medical staff and quality leadership and committees.
Monitors occurrence reports, patient complaints, grievances, generic indicators, serious safety events, and near misses with potential for harm for medical staff-related incidents. Triages to appropriate Professional Practice Evaluation forum(s); immediately notifies appropriate administrative and medical staff leadership of significant events.
Conducts preliminary investigation of occurrence reports, patient complaints, grievances, generic indicators, serious safety events or other event related report, as appropriate, for referral to Professional Practice Evaluation process.
Conducts chart review and prepares case reviews for Professional Practice Evaluation Committees.
Ensures that adverse events are reviewed in a timely manner, reports significant delays in review to the appropriate administrative and medical staff leadership.
Monitors results of Professional Practice Evaluation findings for quality and performance-related issues and trends that may indicate an opportunity to improve care; recommends actions and tracks follow-up.
Provides data support to medical staff committees. Educates committee members on regulatory requirements. Recommends and facilitates improvement activities related to regulatory compliance.
Provides staff support to Care Improvement Committee (hospital Professional Practice Evaluation committee). Prepares cases for review, ensures that notification to appropriate medical staff occurs, and ensures proper follow-up of action items.
Reviews assigned Medical Staff and Department Meeting minutes for accuracy and consistency. Assures that follow-up is done as documented.
Participates in Ongoing Professional Practice design, data oversight, and facilitates actions base on review of data.
Facilitates and supports medical staff leadership in the Focused Professional Practice Evaluation process.
Provides data for external professional practice review upon request.
Develops and fosters strong cross-functional relationships and processes with Patient Safety, Medical Staff Office, Infection Prevention & Control, Quality Improvement, Performance Improvement, Analytics & Clinical Effectiveness, Accreditation & Regulatory Compliance, Stanford Health Care Professional Practice Evaluation and other clinical and administrative departments as appropriate.
Works closely with the Executive Director of the Center for Quality & Clinical Effectiveness and the Vice President of Medical Affairs or their designees to escalate barriers, recommend and implement process improvements and ensure strong relationships with the medical staff.
Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying.
Education: Bachelor's degree in a work-related discipline/field from an accredited college or university, Master's degree preferred
Experience: Three (3) years of progressively responsible and directly related work experience
License/Certification: CA Registered Nurse (RN)
Knowledge, Skills, and Abilities
These are the observable and measurable attributes and skills required to perform successfully the essential functions of the job and are generally demonstrated through qualifying experience, education, or licensure/certification.
Ability to collect and record data, evaluate data and statistics, and maintain effective reporting systems
Ability to communicate effectively, both orally and in writing
Ability to plan, organize, prioritize, work independently and meet deadlines
Knowledge of computer systems and software used in functional area
Knowledge of medical terminology and related levels of care and treatment
Knowledge of statistical analysis and reporting practices pertaining to quality improvement and program evaluation
Knowledge of the current theories, principles, practices and standards of as well as emerging technologies, techniques, issues, and approaches in the nursing profession
Knowledge of the variables that affect the processes and outcomes of patient health care
Physical Requirements and Working Conditions The Physical Requirements and Working Conditions in which the job is typically performed are available from the Occupational Health Department. Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions of the job.
Equal Opportunity Employer
Lucile Packard Children's Hospital Stanford strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, LPCH does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements, and where applicable, in compliance with the San Francisco Fair Chance Ordinance.