Under the supervision of the VP, Clinical & Quality Services, the Regional Director of Regulatory & Quality Services responsibilities will be:
- Supports quality, efficient, safe, and regulatory compliant healthcare services.
- Serves as the primary oversight of facility Quality, Regulatory Preparedness, and Excellence in hospitals
- Oversees and serves as team lead for regulatory preparation and mock surveys for STAC facilities related to TJC, CMS, CAH CMS, CIHQ, DNV, and HFAP.
- Assists hospitals with post-survey action plans, including triennial, state, and mock surveys.
- Conducts and arranges post mock survey 60-90 day validation surveys.
- Presents mock survey findings to the hospitals Governing Board - 90 days post survey.
- Provides information to the QSR subcommittee of the CHC Board of Trustees quarterly and presents the data as requested and directed.
- Serves as Quality Representative during Operations Assessments.
- Assists in providing support to field CNO's, Nursing Directors, Quality and Case Management Leaders in their daily operations, quality initiatives, constituent engagement/satisfaction, patient safety, productivity management, and direction of clinical/quality services.
- Along with VP of Clinical and Regulatory Support, develops and monitors the facility quality scorecards. Reports this quarterly in the MOR reviews.
- Provides leadership support and is a resource for quality and performance improvement at CHC facilities.
- Develops and maintains mock survey master yearly schedule (with approval by VP Clinical Services), each facility's schedule with surveyor assignment, and coordinates the final report writing.
- Maintains constituent satisfaction process, including patient engagement, physician engagement, and the culture of safety surveys. Assists facilities in developing processes to address identified issues.
- Researches answers to regulatory questions or seeks other expert advice when unable to discern difficult regulatory questions.
- Identifies and effectively promotes the resolution of difficult operational and clinical care issues.
- Provide support to facility CEO's and CFO's as requested
- Provides leadership education, direction and support to facility Nursing and Quality leaders.
- May occasionally serve in short-term interim executive CHC field based roles as requested by the VP Clinical Services.
Other General and Related Duties- Performs miscellaneous duties as assigned
- May oversee PRN employees involved in mock surveys, regulatory preparedness, patient safety initiatives, and constituent satisfaction initiatives (patient, physician, and employee engagement).
- Supports and applies CHC's core values of Respect, Integrity, Stewardship and Excellence in the performance of job functions.
- Upholds and supports the company's mission, vision, goals, and objectives
- Complies with CHC policies and procedures as they relate to the performance of job functions.
- Is actively committed to quality of patient care, treatment, and services. Measures and reports quality results to hospital and corporate teams. Fosters continuous quality improvement. Participates in corporate-wide and hospital-based performance improvement activities.
- Is actively committed to providing excellent customer service.
- Strives to meet or exceed expectations/satisfaction in the performance of job functions.
- Is actively committed to meeting and/or exceeding physician expectations/satisfaction in the performance of job functions.
- Retains all regulatory related hospital accreditations, licensures and designations in good standing. Maintains compliance with all laws and applicable regulatory requirements. Acts promptly to comply with required changes.
RequirementsEducation / Requirements - Bachelor's degree in Nursing or related clinical field
- Masters in Nursing or related field is highly preferred
- Must hold current Texas RN license or have the ability to be licensed in the State of Texas
- Will require obtaining HACP certification within the first year of employment.
- Plano based position
- Ability to travel 75% of the time
Experience - Minimum seven years hospital clinical practice experience plus three to five years in a senior nursing or quality leadership position (would consider equivalent years of multi-department nursing oversight)
- Previous consulting experience helpful
- Multi-hospital leadership preferred
- Required familiarity with Quality management, Regulatory Reporting Requirements, Patient Safety, Regulatory Preparedness, Case Management, and Process Improvement Programs
- Rural or small hospital experience desirable
Skills and Knowledge- Ability to assist hospitals in enhancing a quality care environment, positive clinical outcomes, and a high level of patient, physician, and employee satisfaction.
- Ability to read, analyze and interpret quality, clinical, financial and other data.
- Proficient in providing leadership, guidance, direction and oversight of quality leaders at the hospital level.
- Has knowledge to support the basic implementation of case management operations.
- Communicates well verbally in both formal and informal formats.
- Ability to effectively present information and respond to questions from CHC corporate staff members, clinical and medical staff, Board members, hospital leaders, and co-workers.
- May participate in hospital administrative teams, quality management directors, case management directors, clinical leaders, and fiscal leaders in decision making structures and processes.
- Works with people in such a manner as to build cooperation and group commitments to goals and objectives.
- Ability to work independently and manage multiple projects simultaneously.
- Ability to respectfully work with all levels of CHC corporate staff, administration, management, staff, and medical staff.
- Ability to communicate and relate well with others.
- Proficient PC skills.
- Advanced knowledge of regulatory agency standards and the ability to assist hospitals in meeting standards and prepare for surveys and inspections.
- Awareness of hospital productivity standards and how to apply them within hospitals.
- Excellent project management, time management and planning skills.
- Effective organizational skills, attention to detail, and effective follow-through on responsibilities and requests.
- Ability to identify, investigate and resolve issues.
- Possess a high degree of political savvy.
- Ability to travel up to 70% of the time.
- Current driver's license and good driving record.
Benefits A comprehensive health and welfare benefits package is offered as part of total compensation.
- Health Care Plan (Medical, Dental & Vision)
- Retirement Plan (401k, IRA)
- Life Insurance (Basic, Voluntary & AD&D)
- Paid Time Off (Vacation, Sick & Public Holidays)
- Wellness Resources and other benefits
