Summary The Facility Healthcare Program Manager (FHPM) oversees healthcare operations at medium to large ICE Health Service Corps facilities, ensuring compliance with accreditation standards, risk management, and quality improvement. The FHPM reports to the AHSA and manages clinical programs, staff training, emergency preparedness, and supports safe, high-quality care delivery. This position is only open to USPHS officers and Call to Active Duty (CAD) candidates who are currently IHSC employees. Responsibilities 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, 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. 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; 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 ae 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. Accreditation: Monitors and reviews established performance indicators for compliance with national IHSC policies and applicable standards (ACA, NCCHC, PBNDS, and/or FRS). 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 by reviewing processes, updating policy, training staff, and building folders for audit preparation, and record keeping for future 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 if deficiencies are recognized during accreditation audits and health systems assessments. Participates in the Quality Review Process to include performing self-assessments and pre-audit reviews and observations. Serves as liaison between investigators and facility staff and arranges interviews. Provides policy, records, or other documentation required by investigator and prepares responses to action items in coordination with FHSO, FTO, and IPO. 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. Requirements Conditions of Employment Qualifications PHYSICAL DEMANDS: This position is considered hazardous duty in a detention setting. Required to walk unaided at a normal pace for up to 5 minutes and maintain balance. Required to jog/fast walk up to ¼ mile. Requires physical exertion such as lifting objects greater than 30 pounds. Required to perform CPR/emergency care standing or kneeling. Must have the ability to assist sick, injured, or aging detainees or staff exiting the building (may require lifting, dragging, wheeling, or carrying someone who weighs significantly more than self). Must be able to see, hear and smell with aids if necessary. Must be able to lift, push, or carry 30 pounds. Must perform the duties of my job in a stressful and often austere environment without physical limitations. Education 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. Additional Information (Continued from the Duties and Responsibilities section) 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. 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. SUPERVISORY CONTROLS: Incumbent reports to the assistant health services administrator keeping the supervisor informed on the status of projects, and consulting on successes and obstacles. Reviewing official (second line supervisor) is the health services administrator. Performs specialized or complex professional tasks without the benefit of close supervision or detailed guidelines; independently establishes criteria, formulates approaches, and evaluates efforts. Uses judgment in interpreting and adapting guidelines such as policies, regulations, accreditation standards, precedents, and work direction for application to specific situations and work products. Assignments are usually of a long-term, recurring or broadly defined nature and are not accompanied by instructions; however, objectives, priorities and deadlines are provided on new assignments. The incumbent selects his/her own methods and solves most normal problems arising during the course of work. Completed work is usually evaluated for technical soundness, appropriateness, and conformity to professional standards and PHS requirements. Utilizes available guides, methods, theories, and precedents. Situations to which existing guidelines cannot be applied or which require significant deviations from existing guidelines are referred to the AHSA, higher authority and/or subject matter expert. Maintains contact with persons in other federal departments or outside the federal government, such as state or local government officials. Requires face to face contact and telephone dialogue on a routine basis to explain, coordinate, interpret and seek support for policies, procedures, programs, plans or individual actions (often of a controversial and complex nature) in which an extensive amount of explanation and tact is required.