Provides direction, analytical and QM/RM support for initiatives and projects at the system, service line level including but not limited to data analysis, QM/RM facilitation/problem solving, process improvement, and coordinating the implementation of process to assure quality and regulatory compliance.
Skills/Abilities1. Provides assistance to the hospital QM,/RM, service line departments and senior management (facility and division) in professional and timely fashion.
2. Directs activities of DFW market and division teams as needed. Functions effectively as a team member and a team leader.
3. Is aware of and participates in the Corporate Ethics and Compliance Program.
4. Assists division facilities in improving QM/RM and service line processes by providing consultative services that assure a proactive versus reactive approach.
5. Develops, identifies and analyzes data and information for division-wide QM/RM and service line initiatives. Assists customers in appropriate utilization of data from process improvement.
6. Directs and leads activities of the CMO and CEO Councils in collaboration with chairperson and Vice-President of Quality and Patient Safety.
7. Assists facilities with problem solving and process improvement related to regulatory compliance issues, risk management, and improvement in patient outcomes.
8. Assists facilities with TJC survey preparation including assisting with implementation of recommendations from corporate QRS findings.
9. Directs the resolution of TJC or other regulatory issues that have system wide impact as directed by supervisor.
10. Provides and coordinates quality improvement and regulatory related education for hospital and medical staff as deemed necessary by senior management.
11. Orients new QM/RM directors to market and division processes.
12. Continuously evaluates work process and design; understands role in ensuring quality/performance improvement, productivity, and service delivery to meet stakeholder needs.
13. Performs duties in accordance with departmental policies and procedures, and recognized professional, quality, patient safety, environmental and infection control standards.
14. Represents the division at corporate meetings upon request of supervisor.
Responsibilities1. Collaborates with physicians, hospital staff, and hospital and division executive team to address complications and opportunities for improvement identified through data analysis and leading teams through best demonstrated practice and evidence based medicine.
2. Team leadership, group facilitation in a health care setting. Advanced skills in Office 2007 (Word, Excel, Power Point, Access) required.
3. Coordinates collection, interpretation, and analysis of clinical service line data to ensure compliance with accrediting bodies.
4. Identifies and validates the accuracy of the service line’s data collected. Analyzes and compares results against regional and national benchmarks and presents findings to care teams, councils, executive teams, and committees as appropriate.
5. Coordinates registry dashboards with corporate and national benchmarks.
6. Knowledge of statistical process control preferred.
7. Knowledge of regulatory compliance issues required, including, State Health Department, CMS Conditions of Participation, QM and peer review statutes, TJC, OSHA NQF.
8. Seasoned Judgment – apply broad knowledge and seasoned experience when addressing complex issues.
9. Financial Acumen – understand the meaning and implications of key financial indicators; using financial analysis to create and evaluate strategic options and opportunities.
10. Influencing and Negotiating – promote ideas and proposals persuasively; shape stakeholder opinions; project a positive image; work through conflicts; negotiate solutions.
11. High-Impact Delivery – deliver clear, convincing and well-organized presentations; project credibility and poise even in highly visible, adversarial situations.
12. Cross-Functional Capacity – understand the role and interrelationship of each organizational function: have experience and skill in managing across functional and organizational lines.
13. Establishing Strategic Direction – securing information and identifying key issues and relationships relevant to achieving a long-range goal or vision; establishing and committing to a course of action to accomplish a long-range goal or vision after developing alternative courses of action based on logical assumptions and factual information and taking consideration resources, constraints, and organizational values
Job Code: 26500-104900