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of Director Quality, Pt Safety & Reg Compliance
at Trinity Healthcare
Department:32010_77401 QUALITY MANAGEMENT
Expected Weekly Hours:40
Position Purpose:Responsible for planning, coordinating, monitoring and assessing, the Quality Improvement and Patient Care Assessment Program. Responsible for ensuring all requirements are met for Joint Commission and other applicable federal, state, and local regulatory and /or accrediting agencies, i.e. the Board of Registration in Medicine (BORM), the Department of Public Health (DPH), Department of Mental Health (DMH) and Centers for Medicare and Medicaid Services (CMS) on an on-going basis within Mercy Medical Center (MMC) and Providence Behavioral Health Hospital (PBHH). Researches and interprets assigned standards and issues, and assesses impact on Hospital operations. The position will also hold responsibility for continued development of the Mercy quality function including our journey to become a high-reliability organization. Responsible for overseeing and managing the Medical Staff office.
Job Description Details:
PRIMARY JOB RESPONSIBILITIES AND DUTIES:
1. Quality and Regulatory Leadership:
a. Oversees Quality Department and associated functions
b. Supervises-Quality Department
c. Leads Joint Commission accreditation and State of Massachusetts licensure/renewal activities
d. Oversees Mercy regulatory activities including the successful management of all regulatory and quality reporting
e. Drives the quality initiative to become a high-reliability organization
2. Responsible for initiating intensive investigations and root cause analysis as defined by the organizational policies and procedures. Notifies Directors of incidents of high-risk significance.
3. Maintains ongoing hospital wide accreditation status, directs the self-assessment process as required by the Joint Commission. On annual basis, assesses, coordinates, and submits the self-assessment tool. Serves as the hospital’s coordinator for each self-assessment tool (MMC and PBHH). Monitors action plans throughout the year for compliance.
4. Works in concert with the Manager of Risk and TH Of NE Regional Director of Risk Management, when necessary, in gathering and documenting information pertaining to all potential liability claims and high-risk areas.
5. Assists directors in the coordination of on-site investigations by various external reviewers i.e., DPH, DMH, Joint Commission, and BORM.
6. Assists directors in the implementation and ongoing measurement of various Trinity Health initiatives which include Patient Satisfaction, Peer Review, Credentialing at MMC and PBHH.
7. Responsible for quality review data collection, analysis and reporting to the Mercy Patient Safety, Quality Improvement Committee, the Mercy Medical Record Committee, and Mercy Pharmacy and Therapeutics Committee.
8. Responsible for the oversight and management of the Medical Staff Office including ensuring compliance with Joint Commission, Center for Medicare and Medical Services and other relevant compliance, quality and safety standards. Ensures proper credentialing and privileges for physicians and other medical staff.
9. Ensures the proper selection, training, development, motivation, evaluation, and retention of competent colleagues. Responsible for counseling and disciplining staff up to and including termination. Creates and encourages a positive, team-oriented work environment within department. Resolves complex colleague relations matters.
10. Responsible for overseeing the data collection and reporting to various external reporting organizations such as the BORM, DPH, Blue Cross/Blue Shield Collaborative and Mass Health.
11. Responsible for maintaining Joint Commission compliance with the Performance Improvement and National Patient Safety Goals.
12. Participates in performance improvement activities by acting as a team member, leader, coach, or facilitator.
13. Assists in the development and implementation of policies, procedures and objectives for quality improvement, infection control, and risk management, as needed.
14. Conducts ongoing educational programs in quality improvement and infection control.
15. Responsible for preparing reports for various committees as assigned by the directors. Prepares summary of information needed for the BORM for semi-annual and annual reports.
16. Supervises staff maintaining the physician’s quality peer review files for inclusion in the peer review process for reappointment.
17. Supervises staff coordinating quality reviews, and reports findings of ongoing reviews to the medical staff peer review committee.
REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:
1. Work requires the knowledge of theories, principles and concepts acquired through completion of a Bachelor’s degree in Nursing or related healthcare field, Master's preferred.
2. Massachusetts license in nursing preferred. Will consider 5 to 10 years of strong healthcare related experience in lieu of nursing license. Requires a minimum of five (5) years of progressively more responsible healthcare-related experience. Minimum of three (3) years previous supervisory experience of professional clinical and support staff.
3. Requires experience in Quality Improvement concepts and tools, Risk Management, Joint Commission, and nursing management. Certified Professional Healthcare Quality (CPHQ) required or must be obtained within two (2) years of hire in position.
4. Knowledge of Word, Excel and Power Point with proficient skills in maintaining database spreadsheets and report writing and presentations.
5. Demonstrated strong leadership experience that includes excellent written and verbal communication skills. Business acumen to effectively project manage, understand and work with financial statements, and to negotiate in extremely important, sensitive, and complex situations.
6. Work requires the analytical ability necessary to resolve problems requiring a professional level of knowledge in a specific discipline/field and/or design complex clinical, financial, data processing marketing or human resources systems and programs. Strong interpersonal leadership skills.
7. Demonstrated clinical knowledge, as well as demonstrated knowledge of quality improvement, patient safety, peer review, and compliance.
8. A high degree of ethics and confidentiality is essential for dealing with highly sensitive patient care and peer review matters. Ability to work with multiple levels in the organization including staff, managers, directors, senior leaders, medical executive committee, and board of trustees.
1. Requires working in a normal office environment. Requires regular use of a computer or similar device, electronic equipment, etc. Minor lifting under 15 pounds; regular bending, stooping and sitting.
2. Must be able to balance, manage and adapt to frequently changing work priorities and be able to prioritize and balance the requirements of working with the TH Of NE System Office and Regional Health Ministries (RHMs).
3. Requires travel to and from the various TH Of NE sites as needed.
1. Reports directly to the Chief Medical Officer.
2. Has the responsibility for the direct supervision of 15 – 20 colleagues.
Trinity Health's Commitment to Diversity and Inclusion
Trinity Health employs about 133,000 colleagues at dozens of hospitals and hundreds of health centers in 22 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.
Trinity Health's dedication to diversity includes a unified workforce (through training and education, recruitment, retention and development), commitment and accountability, communication, community partnerships, and supplier diversity.
Trinity Health is one of the largest multi-institutional Catholic health care delivery systems in the nation. It serves people and communities in 22 states from coast to coast with 93 hospitals, and 120 continuing care locations — including home care, hospice, PACE and senior living facilities - that provide nearly 2.5 million visits annually.
Trinity Health employs more than 120,000 colleagues, including 5,300 employed physicians. Committed to those who are poor and underserved in its communities, we are known for our focus on the country's aging population. As a single, unified ministry, Trinity Health is the innovator of Senior Emergency Departments, the largest not-for-profit provider of home health care services — ranked by number of visits — in the nation, as well as the nation’s leading provider of PACE (Program of All Inclusive Care for the Elderly) based on the number of available programs.