Facility Healthcare Program Manager (O-5 Billet) Non-Supervisory

Administration

• Works collaboratively with the health services administrator as the subject matter expert and key advisor in the day-to-day management, development, implementation and monitoring of the following IHSC programs of responsibility: accreditation readiness and standards compliance, risk management, and quality improvement.
• Serves as a key member of IHSC national risk management and quality improvement program initiatives, not limited to attending regional/national meetings.
• Makes sure to monitor, review, coordinate, and ensure complete and timely reporting of accreditation readiness and standards compliance, risk management, and quality improvement activities.
• Conducts data/trend analysis and implement improvement strategies establishing timeframes for continued monitoring concerning all programs of responsibility.
• Secures and maintains all files and information concerning all programs of responsibility in accordance with all established policies, procedures, and regulations.
• Develops and maintains accreditation readiness and standards compliance; risk management; quality improvement; infection control; occupational health; environmental health, safety and security; and all hazards emergency preparedness and response local operating procedures as applicable; forwards revisions and updates to HSA for approval.
• Ensures accreditation readiness and standards compliance; risk management; quality improvement; infection control; occupational health; environmental health, safety and security; and all hazards emergency preparedness and response standards, including updates on national and local policies and procedures, are disseminated appropriately to staff in a timely manner.
• Regularly coordinates efforts with FHSO, FTO, and IPO.
• Provides policy, records, or other documentation concerning all programs of responsibility as required by investigators.
• Serves as federal fit tester conducting fit testing for federal staff.
• Ensures all staff meets annual fit testing requirement.
• May be asked to perform duties of the FHSO programs of responsibility: infection control; occupational health; environmental health, safety and security; and all hazards emergency preparedness and response when needed.
• May be asked to serve as an acting HSA or AHSA when needed.

Risk Management

• Provides leadership and oversight of the local risk management program including develop, coordinate, implement, and monitor associated tasks and duties.
• Assists HSA and AHSA with the investigation of incident reports and adverse events (i.e. root cause analysis, mortality reviews, etc.).
• Conducts data/trend analysis, develops action plans, implements improvement strategies establishing timeframes for continued monitoring, monitors effectiveness of change, and modifies action plans as needed to yield positive outcomes.
• Prepares facility responses to correct the identified process issues and reporting findings/recommendations in writing through established chains of communication within specified timeframes.
• Obtains HSA and AHSA approval prior to submission.

Quality Improvement

• Provides leadership and oversight of the local QI program including develop, coordinate, implement, and monitor national and local performance measures, associated tasks, and duties.
• Chairs the local QI committee meetings.
• Conducts data/trend analysis and implements improvement strategies establishing timeframes for continued monitoring.
• Completes quarterly and annual reports and communicates findings to staff in a timely manner.
• Identifies, conducts, analyzes, and evaluates studies [i.e. patient education, process, outcome, healthcare failure modes & effects analysis, etc.].
• Educates staff on rationale, procedures, and subsequent process changes in a timely manner.
• Reports findings, recommendations, and education in writing through established chains of communication within specified timeframes.

Training

• Provides leadership, oversight, staff training and education on compliance with standards and accreditation, risk management (i.e. incident reporting, patient safety, etc.), and quality improvement.
• Aids HOST FHPM with new FHPM orientation as needed.
• Coordinates with FTO on all trainings.
• Obtains HSA and AHSA approval prior to implementation.
• Serves as CPR Instructor.
• Conducts BLS certification for all federal staff and provides CPR card upon completion.