SUMMARY

The Facility Healthcare Program Manager (FHPM) oversees clinical programs, accreditation readiness, risk management, and quality improvement at medium to large ICE Health Service Corps facilities. Requires a master’s degree, 5+ years of experience, strong project management skills, and CPR certification. Duties include staff training, compliance monitoring, and emergency preparedness

REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES:

• Minimum of a master’s degree in a qualifying program for USPHS Commissioned Corps officers.
• Minimum of five years of relevant and related experience(s).
• If the incumbent holds a clinical license, it is the responsibility of the incumbent to fulfill the obligation(s) of their licensing or certifying body to maintain current status. This position may be required to perform clinical activities with the scope of clinical license in times of critical needs within the agency.
• Ability to critically analyze situations, data and information and be able to develop and pose probing questions.
• Strong project management, quality management, and performance improvement skills to include the ability to plan and prioritize workload, conduct surveillance, employ research techniques, collect, and analyze data, and perform program reviews and evaluations.
• Ability to interact well and collaborate with all levels of personnel and management in IHSC, ERO, ICE and DHS offices, and with Federal contractors
• Proficiency with electronic health records and ability to quickly develop competency with IHSC’s electronic health record.
• Demonstrates the ability to quickly develop competency in and assimilate knowledge of ICE and IHSC rules, regulations, and policies; applicable detention health care standards PBNDS, NCCHC, ACA, FRS (if applicable to the facility), U.S. Occupational Safety and Health Administration (OSHA) regulations, and National Fire Protection Association (NFPA) Life Safety Codes; and the accreditation/compliance review and auditing processes.
• Proficiency with Microsoft Word and Excel; ability to manage, organize, and analyze complex information using spreadsheets and other data management tools.
• Demonstrates high level, professional, effective written and verbal communications; executes effective teaching skills ensuring goal directed outcomes; ability to prepare reports in electronic formats.
• Maintains basic readiness status.
• Maintains current CPR/BLS certification.

DUTIES AND RESPONSIBILITIES:

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 (RM), and quality improvement (QI).
• Serves as a key member of IHSC national risk management and quality improvement program initiatives, not limited to attending regional/national meetings.
• Monitors, reviews, coordinates, and ensures 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 and in coordination with FHSO, FTO, and IPO. Forwards revisions and updates to HSA for approval.
• Ensures accreditation readiness and standards compliance.
• 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
• Travel required up to 25% as directed by the chief of Health Operations Unit

Accreditation:

• Monitors and reviews established performance indicators for compliance with national IHSC policies and applicable standards.
• Collaborates with the HSA and AHSA in performing assessments of the health unit for accreditation under the appropriate standards and ensures the preparation of the health unit for any accreditation the facility undergoes.
• Prepares the facility for accreditation/re-accreditation audits.
• Ensures compliance standards, including updates on national and local policies and procedures, are disseminated appropriately to staff in a timely manner.
• Develops recommendations for improvements and success action plans (SAPs) if deficiencies are recognized during accreditation audits and health systems assessments.
• Participates in the Quality Review Process (QRP) to include performing self-assessments and pre-audit reviews and observations.
• Serves as liaison between investigators and facility staff and arranges interviews.

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.
• 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. 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, and quality improvement.
• Assists 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.
• Other duties as assigned