Director, System Policies, Procedures, Guidelines & Clinical Forms

At Memorial Hermann, we pursue a common goal of delivering high quality, efficient care while creating exceptional experiences for every member of our community. When we say every member of our community, that includes our employees. We know that when our employees feel cared for, heard and valued, they are inspired to create moments that exceed expectations, while prioritizing safety, compassion, personalization and efficiency. If you want to advance your career and contribute to our vision of creating healthier communities, now and for generations to come, we want you to be a part of our team.
Job Summary
The Director, System Policies, Procedures, Guidelines (PPG) and Clinical Forms will perform advanced professional and program management work in the operation and/or planning of the key Memorial Hermann governance medical forms documentation. Work involves coordination of all operational and planning activities for policy, procedure, clinical guidelines (PPG), Clinical Forms, ADA oversight, and Nursing Peer Review functions for the Memorial Hermann Health System. The position leads efforts to refine and improve current processes, enhances the use of technology, oversees implementation of new technology or enhancements to ensure that MHHS PPG and Clinical Forms are maintained and of high quality. This position is also the System Civil Rights Coordinator and assists with the management of grievances and complaints alleging discrimination under the ADA. This position directly supervises a System Policy, Procedure, and Clinical Forms Coordinator, and the System ADA Coordinator while supporting the facility-based Policy and Procedure Coordinators and facility-based Forms Coordinators. This position typically reports to the Vice President, Chief Risk and Litigation Officer.Job Description
MINIMUM QUALIFICATIONS
Education: Bachelor's of Nursing degree from an accredited school of professional nursing required; Master's degree preferred.
Licenses/Certifications: Current State of Texas license/permit to practice professional nursing required.
Experience / Knowledge / Skills:

• Ten (10) years of experience in a clinical health care setting, including three (3) years of clinical teaching experience and three (3) years of management experience.
• Experience working with Americans with Disabilities Act (ADA) preferred.
• Effective oral and written communication skills.
• Must be a detail-oriented individual with the ability to work independently to achieve required objectives.
• Demonstrated progressive knowledge and work experience in clinical practice.
• Experience with and ability to use a variety of computer programs and applications.
• Ability to collaborate with staff at all levels of the organization and multiple facilities to review and implement key operational processes.
• Ability to express ideas effectively, both orally and in writing.
• Proven team building skills in dealing with multidisciplinary clinical and operations teams, including physicians, in diverse settings; effective as a change agent.

• Coordinates the activities of the System-wide Policy and Procedure Committee.
• Partners with and supports facility/entity Policy and Procedure Coordinators, including issue resolution as needed.
• Provides oversight and direction for PPG development, approval, and publishing changes that may be required due to MHHS legal, structural, or regulatory changes (for employees, vendors and physicians).
• Collaborates with and coordinates the review and approval of PPG documents with the MH Legal Services Department as appropriate.
• Ensures that System-wide policies on document development are up-to-date and followed by Memorial Hermann facilities/entities.
• Collaborates with vendor and MHHS ISD to secure contract and annual maintenance renewals.
• Collaborates with vendor and MHHS ISD to resolve technical issues related to the PPG platform.
• Collaborates with vendor in product improvement.

• Provides direct supervision and oversight of System Forms Coordinator and System Forms Committee.
• Provides oversight and direction for forms development, approval, and publishing changes that may be required due to MHHS legal, structural, or regulatory changes.
• Provides indirect oversight and support for facility/entity Forms Coordinators.
• Ensures that System-wide policies on Clinical Forms development are up-to-date and followed by Memorial Hermann facilities/entities.

• Serves as System Civil Rights Coordinator.
• Provides oversight for ADA Section 504 and ACA Section 1557 compliance and activities.
• Provides direct supervision of System ADA - 504 Coordinator.
• Coordinates ADA grievance and complaint investigations enterprise-wide

• Coordinates the activities of the System-wide Nursing Peer Review Committee.
• Provides individual case consultation and guidance to entity-based Nurse Peer Review chairs and Chief Nursing Officers (CNOs).
• Reviews and/or authors Employer's Reports to the Texas Board of Nursing.
• Facilitates implementation of new entity-based NPR Committees as necessary.

• Maintains and updates PPG, Forms, Nursing Peer Review, ADA - 504, Enterprise Risk Management, and Operations Administrator access and informational websites on MHHS intranet site.
• Provides training and education as necessary to support the PPG, Clinical Forms, Nursing Peer Review, and ADA processes.
• Creates/provides reports and updates to leadership on any issues related to PPG, Clinical Forms, and Nursing Peer Review.
• Locates, prepares and produces PPG documents in response to subpoenas and requests for production received by MHHS attorneys, to include Risk/Claims, Employment, Litigation, and Clinical Operations.
• Collaborates with the Legal Department in responding to BON, TMB and other third-party legal subpoenas.
• Locates, prepares, and provides PPG documents as requested for regulatory and disease-specific certification applications and recertifications (i.e., Magnet®, Maternal and Neonatal leveling, Stroke and Chest Pain certifications).
• Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
• Demonstrates commitment to caring for every member of our community by creating compassionate and personalized experiences. Models Memorial Hermann's service standards of providing safe, caring, personalized and efficient experiences to patients and our workforce.
• Other duties as assigned.