This role will be responsible for managing and coordinating quality and risk initiatives, Medical Staff Services, Patient Safety and Emergency Preparedness in order to support the division strategic plan and goals, and meet HCA quality objectives and standards. In this regard, s/he will have responsibility for facilitating and coordinating activities in:
- Clinical excellence and patient safety
- Process improvement and outcomes management
- Regulatory readiness
- The Vice President will coordinate his/her work closely with the HCA Clinical Services Group, the Division Chief Medical Officer, the Division Chief Nurse Executive, the Division VP of Performance Improvement, and the Division Director of Case Management. Responsible for ensuring facility compliance with The Joint Commission, Centers for Medicare and Medicaid Services (CMS) Conditions of Participation, licensure and other standards, rules and regulations
- Lead the continuing development of the quality infrastructure across the division. Insure that resources are leveraged to maximize support of the hospitals and achievement of goals.
- Facilitate the growth of division and hospital knowledge regarding quality, and related areas, including the dissemination of "best practices" across the division.
- Lead division-wide standardization in targeted process improvement initiatives, and evaluate success through pre-established criteria.
- Lead proactive patient safety activities to create hospitals that are high reliability organizations, as reflected in reduced errors, elimination of unsafe processes, and increased involvement of staff and physicians toward a culture of safety.
- Contribute to the achievement of business and financial goals through optimal division performance in quality and patient safety.
- Interface with appropriate personnel at HCA to leverage corporate resources, programs, tools, and methodologies for benefit of division hospitals.
- Collaborate with and support hospital quality directors to achieve top ranking in national and state publicly reported data initiatives.
- Participate in regular analysis of division quality and risk performance data, and plan steps for ongoing improvement.
- Work with Division CMO, Division CNE and Division Director of Data Management to support data analysis, reporting, and outcomes improvement. Contributes to ongoing enhancement of division quality reporting methods and dashboards.
- Continuously monitor and evaluate quality outcomes for patient care across the division, while noting trends, and identifying and prioritizing opportunities to improve.
- Ensure the reporting of data to approved third parties, such as Leapfrog, NCDR & STS databases, etc.
- Assist facilities in building a proactive quality department by implementing tracer teams responsible for identifying processes that are non-compliant with Joint Commission, COP, Title 22 and other regulatory requirements.
- Facilitate and/or lead clinical process improvement teams as needed to achieve quality improvement goals.
- Serve as a regulatory resource regarding state and federal regulations and standards, including but not limited to CMS, Joint Commission, CDC and applicable state laws.
- Stay current with NQF, AHRQ, Leapfrog, IHI and other quality performance initiatives.
- Demonstrate personal responsibility for professional development, and promote and support such development with division hospital quality directors, risk managers, infection preventionists and medical staff office personnel.
- Promote a culture that is positive, that values individual strengths, takes risks, and is committed to optimal patient care, and compliance with standards.
- Attends HCA-mandated training and meets all ethics and compliance standards and requirements. Develop and implement division level projects as directed by Division CMO and Division CNE.
- Promote consistent positive patient interactions that advance the agenda of increased patient satisfaction
- Practice and adhere to the "Code of Conduct" philosophy and "Mission and Value Statement"
- Master's degree (MHA, MBA, MSN, or related field), or near degree completion
LICENSES, CERTIFICATIONS, & TRAINING:
- Clinical licensure, preferably RN, required
- Certified Professional in Healthcare Quality (CPHG) preferred
- Cert Prof Healthcare Risk Management preferred
- 5+ years of experience in patient safety, risk and quality improvement
- Management experience preferred
- Previous experience within a multi-facility environment
- Working knowledge of healthcare laws and regulations
- Strong leadership, creativity, and excellent communication skills, written and verbal, with the ability to tailor the message to individuals and audiences across the organization.
- Excellent analytical and problem-solving skills
- Demonstrated ability to work with all levels of management, clinical and IT&S staff
- Initiative and ability to work independently and handle multiple priorities
- Ability to facilitate group and team process improvement
- Ability to establish and maintain long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations