To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values-integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
Reports to the Director, Quality Services with a matrixed relationship with the Executive Director, Safety and Quality, Medical Directors, Chief Quality Officer (CQO) and Chief Medical Officer (CMO) as assigned. The incumbent will provide strategic direction for the overall quality measurement, safety programming, and operations programming as applicable.
Quality Measurement: Provides expert consultation and support to all delivery networks in YNHHS regarding external benchmarking databases and public reporting. Guides the reliability processes in terms of data integrity across YNHHS as requested. The incumbent will direct the performance components of the YNHHS Performance Improvement Plan, PIP and other business plans as applicable. Oversees the design, methods, execution, timeline analysis and reporting of YNHHS quality measurement projects and programs in collaboration with the Medical Directors. This will include, but is not limited to oversight of the dissemination of reports, interpretive presentation and ongoing consultation to all areas of the hospital. The incumbent is responsible for direction of the analytic and project management focused staff as assigned to include all areas of training, competency validation, ongoing supervision, setting goals, assessing progress and/or barriers, planning remediation as needed adjusting performance expectations as well as conducting performance reviews.
Quality and Safety Operations: Provides leadership in development, implementation in organization-wide quality and safety structures as designed by senor leadership. This includes all management of logistics, memorialization of organizational decisions, support and collaboration with JDAT and other data teams to provide information that is translatable into knowledge for ongoing process improvement. The incumbent will be responsible for completing annual organizational assessments of priorities by completing a strategic crosswalk of measurements, environmental scan, sensing session, etc. to define a concrete set of goals for the following year. S/he will then be responsible for directing support and measurement to team-based improvement work with demonstrable outcomes.
1. Directs all training, competency validation and provides ongoing oversight to all data processes including IRR, other validation and data display checks while working collaboratively within the YNHHS system and external benchmarking agencies to assure the highest standard of quality information is available at all times.
2. Completes an annual environmental scan of all available data sources and critically analyzes performance to make recommendations to Senior Leadership on organizational priorities.
3. Develops and participates in quality projects and facilitates the dissemination of results through interpretive presentations, automated electronic reports, and/or publications.
4. Directs analytic and abstraction staff as assigned. This includes management of data quality and integrity through high reliability processes.
5. Directs the development and integration of internal databases with other Epic, other delivery networks and external benchmarking information systems to facilitate, evaluate and assess the quality of health care surveillance and outcome research.
6. Enhances knowledge in the field of infection prevention, clinical quality improvement, healthcare quality monitoring, federal and state regulatory guidelines, standards, and practices by attending meetings, visiting other sites, reading, reporting and disseminating relevant literature. Publishes best practices.
7. Demonstrates high-level knowledge and skills in key behaviors that reflect expertise in communication, customer service orientation, professionalism, problem solving, resource management, results orientation, teamwork and cooperation, business and organizational expertise, leadership, and managing performance.
8. Directs production of reports to senior leadership and collates and summarizes quarterly reports as requested by the Medical Directors.
9. Reports data from special projects and other quality reports to appropriate individuals, departments and committees.
10. Serves as the liaison to outside agencies such as Vizient, CHA, Joint Commission, Premier and Qualidigm as well as a resource for other YNHHS Delivery Networks in the areas of quality improvement, quality measurement and quality operations.
11. Provides support and consultation to stakeholders as related to design, upgrading and implementation of survey instruments and systems. Directs surveys and qualitative assessments across the organization.
12. Provide education and consultation to senior leadership in regard to changes in criteria, new data collection tools and/or methods as well as medical record abstraction guidelines.
13. Directs and/or coordinate special projects as directed by CMO, CQO, Medical Directors or other senior leaders to promote continuing evaluation and improvement in processes and patient care outcomes.
14. Develop a plan for managing the data components of organizational responsibilities in collaboration with the Directors to support the high reliability mission and the YNHHS mission, vision, values.
15. Manages, recruits, hires, administers disciplinary action and conducts job performance reviews for staff assigned to incumbent.
16. Meets frequently with employees and plans mutually agreed upon individual performance goals. Monitors progress and/or barriers, plans remedial education and/or training, modifies performance expectations, and completes six-month and twelve-month reviews as required.
17. Mentors staff across the system in quality measurement.
18. Maintains an exceptional work environment through effective leadership, direction, supervision, role modeling, and communication.
19. Schedules, plans, facilitate, and conduct staff meetings.
20. Plans, facilitates, tracks, and modifies the organizational performance goals and action plans annually and as necessary.
21. In the absence of the Director, represents requesting leaders at hospital management meetings.
22. Develops and monitors timetables, budgets and resources necessary to complete goals and projects.
23. Performs other assignments as required and/or directed by CMO, CQO and/or Medical Directors, Infection Prevention, Patient Safety and Quality
Master's Degree in Nursing, Public Health, Health Care Administration, or other health related field required. Certified Professional in Healthcare Quality (CPHQ) highly desirable and must be completed within 2 years of employment
5-7 years of experience in Quality Improvement and/or Performance Management with demonstrated leadership skills and clinical and financial outcomes.
Maintains certification as Certified Professional Healthcare Quality (CPHQ). RN licensure preferred but not required.
Excellent interpersonal, communication organizational and leadership skills. Ability to work collaboratively and independently. Demonstrated person maturity and good judgment. Expert knowledge of quality improvement methods, processes and practices relating to patient care and clinical outcomes. Demonstrated knowledge of quantitative and qualitative data management including but not limited to entry, analysis, interpretation, validation, reliability. Demonstrated proficiency in Microsoft Office software (Word, Excel, PowerPoint and Outlook) and YNHH information systems (Epic, Theradoc) and external databases (QNet, NHSN).
Responsible for directing the planning, development, coordination, implementation and evaluation of the multiple facets of the performance management program primarily within YNHH but also with consultation to YNHHS Delivery Networks. Reports directly to the Director of Quality Services with matrixed reporting to the CMO and his/her Medical Directors.
In personal and job-related decisions and actions, consistently demonstrates the values of integrity (doing the right thing), patient-centered (putting patients and families first), respect (valuing all people and embracing all differences), accountability (being responsible and taking action), and compassion (being empathetic).