Full Job Description
The Quality Management department is responsible for quality and safety performance including all required regulatory and public measures reporting (CMS), balanced score care initiatives, HAI prevention across the health system. This department provides oversight and governance for the Quality Assessment and Performance Improvement mandates for CMS-CoPS, and Joint Commission. Additionally, the team provides subject matter expertise in quality and data analytics, improvement, regulatory readiness (measures, dashboard and analysis); Supports councils and clinical care redesign initiatives.
The Regional Regulatory Program Manager designs, develops and implements performance improvement and compliance activities within the Fairfield Region of Hartford HealthCare. Responsibilities include but, are not limited to the following:
- Participate/Lead in Department of Public Health/ CMS licensure and investigative surveys, including coordination of follow up activities.
- Provide subject matter expertise with accreditation standards and regulatory requirements through training/coaching, tracer activities, program assessments, data collection and analysis of outcomes.
- Design, develop and implement performance improvement and monitoring activities to meet or exceed accreditation and regulatory requirements to maintain an environment of continuous readiness for accreditation and licensure surveys for the Northwest Region.
- Perform routine tracers and audits in clinical and non-clinical areas to identify improvement opportunities
- Leads Performance Improvement initiatives for departmental clinical leadership and front-line staff in establishing a comprehensive quality assessment and performance improvement plan.
- Utilizing internal and external data to identify issues and trends that impact patient safety and quality of care. Collaborates with regional leadership and front-line staff in formulating plans to address identified concerns. Examines data with clinical knowledge and recommends strategies to improve clinical performance and enhance patient safety.
- Participates in and/or leads performance improvement teams as indicated and according to the organization's priorities.
- Performs quality and safety monitoring activities necessary to support clinical and administrative staff with ongoing evaluation of care processes and outcomes.
Qualifications:
Education:
- Bachelor's degree in Nursing, Hospital Administration, Public Health or other related field
Experience:
- Five (5) years nursing experience in an acute-care hospital setting required
- Three (3) years of experience with accreditation and regulatory survey process, development, and follow up of corrective action plans or an equivalent combination of education and experience, preferred
Licensure, Certification, Registration:
- Current Connecticut Nursing License
Knowledge, Skills and Ability Requirements:
- Strong written and oral communication skills; strong interpersonal skills, ability to work with others collaboratively to achieve common objectives
- Ability to compile data from various sources and to analyze and interpret the data in order to provide alternatives and make recommendations
- Able to use Microsoft Office, including Word, Excel, PowerPoint and Outlook
- Manage multiple priorities and projects from initiation to completion within prescribed schedules and utilization of resources
