National Patient Safety Quality Management Director

Job description

Contracted medical staff will be working alongside uniformed Customs and Border Protection (CBP) Agents/Officers in secured federal facilities along the southwest border of the United States. These secured federal facilities are staffed and monitored by CBP personnel and/or contracted security staff 24 hours a day, 7 days a week to assure a safe working environment to include the co-located medical unit. Contracted medical staff work together with CBP personnel to provide health care services for persons of all ages, to include infants, children, adults, and pregnant females.

Mission

CBPs Office of the Chief Medical Office (OCMO) employs a family medicine model to provide frontline medical care for persons in CBP custody. This model provides a team of medical professionals comprised of physicians, advanced practice providers (e.g., physicians assistants, nurse practitioners), clinical support staff (e.g., Licensed Practical/Vocational Nurses, Paramedics, EMTs, Certified Medical/Nursing Assistants), and other support staff (Patient Safety Risk Managers and Electronic Health Records Specialists). These contracted medical teams provide basic assessment and medical treatment for persons in CBP custody to include emergency care as needed. OCMO is committed to ensuring a system of care that is ethical, responsible, and accountable through surveillance and monitoring activities that are in place. DHS/CBP Contracting Officer Representative (COR) and/or Contracting Officer, as applicable

BASIC REQUIREMENTS

Licensure/Certification:
1.    Candidates must be currently licensed to practice as Registered Nurse in a State or territory of the United States or the District of Columbia. Licensure must be maintained current, and any required education, trainings, continued learning to maintain licensure must be completed within the required timeline for completion by the licensing authority. A temporary license will not be accepted.
2.    Candidate must not have had any professional licensure or certification withheld, suspended, revoked, or denied, and the candidate must not have surrendered or allowed a professional license or certification to have expired or lapsed because of an investigation or disciplinary action.
3.    Candidate must not have been convicted of, pled guilty to, pled nolo contender to, or received probation before judgement for any crime other than a minor traffic violation, the record of which has not been expunged.
 
Education/Experience:
1.    Graduate from an accredited baccalaureate Registered Nurse Program located in a State, the District of Columbia, or a U.S. territory. The degree issuing institution and/or program must be accredited by an entity recognized by the U.S. Department of Education.
2.    Must have a minimum of five years of clinical experience in direct patient care as a registered nurse and at least three years of experience in risk management, patient safety, and quality management.
3.    Experience in detention/correctional healthcare, ambulatory care, or a pediatric care setting encouraged, but not required.
4.    Supervisory experience preferred, but not required.

Duties and Responsibilities:

1.    Responsible for the creation and management of a comprehensive quality, health, safety,
and risk management program
2.    Ensures the medical units’ obligations under prevailing state and federal guidelines pertaining to quality, health, and safety are met
3.    Creates and manages a proactive standardized Risk Management Plan that fully addresses risk and incident management across all medical units, and adheres to DHS, CBP, federal, and state (if applicable) policies and guidelines
4.    Supervises and manages the duties and activities of the Patient Safety Risk Manager (PSRM) at each sector/region
5.    Creates, implements, and executes a Quality Assurance and Performance Improvement Plan to include process and outcome initiatives, training, monitoring, evaluation, and quarterly summary reports to promote a safe work environment, and quality patient care
6.    Collaboratively oversees and manages the identification and review of all incidents, to include Medical Sentinel Events
7.    Works collaboratively with the National Medical Director on the completion of Root Cause Analyses of all medical sentinel events, to include tracking, trending, and managing any implementation plans resulting from the Root Cause Analysis and addressing any improvements recommended
8.    Develops and maintains a tracking system for all incidents, noting trending, and any
significant findings in a quarterly summary as part of the Medical Quality Management
9.    Creates and implements Standard Operating Procedures and Policies for the medical units, to include but not limited to guidance on patient care, procedures for performing diagnostic testing, documentation, and medical quality
10.    Collaboratively leads the National Medical Quality Management meetings, and oversees the completion of minutes, attendance, and follow through on any items discussed or identified
11.    Initiates and maintains compliance with DHS and CBP policies and any overriding standards that may apply
12.    Monitors staff compliance with policies and procedures, creates a monthly training schedule for staff to maintain currency with policies and procedures
 

Duties Cont

13.    Oversees compliance with Clinical Laboratory Improvement Amendments (CLIA).
14.    Oversees or is responsible for all support staff competency testing, training completion, and electronic medical record training completion
15.    Oversees that all OSHA required training and testing is completed for all staff, and makes recommendations to leadership for any needed supplies, equipment, or processes that need implementation. Oversees the management of the Safety Data Sheets manual in each medical unit, and training on it use.
16.    Performs annual inspection of each medical unit; works with the Patient Safety Risk Managers to always maintain medical units “inspection ready”; Performs ad hoc on site visits as needed or required by CBP or OCMO; Reports all findings in a written format report to National Medical Director and National Program Manager for follow through, recommendations, and oversees completion of any corrections needed
17.    Coordinates and/or develops on-going quality assurance activities for medical services to monitor compliance with standards and regulatory requirements through rounds, interviews, and record reviews. Helps the National Program Director prepare staff for inspection surveys, instructing staff on matters of conduct and disclosure, being interviewed by inspectors, immediate corrections of problems noted by surveyors, etc. Reviews and reinforces important standards previously cited
18.    Works within licensure/certification and position description
19.    Maintains compliance with standard operating procedures and protocols
20.    Maintains patient confidentiality and privacy of medical records
21.    Performs record keeping functions in accordance with program policies and the system of
records management
22.    Ability to use the electronic medical record, and must maintain an “active status” for use
and complete all required trainings
23.    Utilizes the electronic medical records system for any patient documentation, to include, but not limited to direct patient care, monitoring, medication administration/observation documentation, and input of any paper records as applicable
24.    Maintains non-involvement in the security aspect of patient care and custody
25.    Attends national meetings, local staff meetings during site visits, and collaboratively
leads medical quality management initiatives and reviews
26.    Assures a safe and clean working environment, and assists in the disposal of biologically hazardous waste on a regular basis as needed
27.    Completes all annual training as directed
28.    May be required to travel to CBP headquarters for meetings or as needed
29.    May be required to serve at various medical units within sector/region as requested by
CBP or OCMO
30.    Will effectively create spreadsheets, diagrams, PowerPoint presentations, and other forms

Duties Cont

of training or reporting, using Microsoft Office or other technology-based software
31.    Creates other ad hoc reports and summaries, as needed, or requested by CBP, COR, or
OCMO
32.    Works with OCMO to review and clarify any reporting requirements, address any
auditing concerns or findings as needed
 
33.    Performs other duties and responsibilities as assigned

Supervisory Controls:
1.    Works under the administrative direction of the National Deputy Medical Director, or in their absence the National Medical Director.
2.    Works under the clinical supervision and/or direction of the Deputy Medical Director, or in their absence, the National Medical Director.
3.    In this position, the employee will serve as a contractor to the federal government and does not have any federal authority or rights.

Physical Demands:
1.    Able to walk, stand, bend, or sit for extended periods.
2.    Able to reach to retrieve documents or supplies.
3.    Able to carry materials and/or file boxes up to 30 pounds on an infrequent basis, or assist patients into/out of a wheelchair
4.    Must be capable of standing on hard surfaces (cement floors) for long periods of time
5.    Must perform the duties in a stressful and often austere environment without physical
limitation