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.Under the direction of the YNHHS Executive Director, Safety and Quality, the incumbent directs and manages operations of the quality and safety components of the strategic quality and safety agenda. S/he works extensively with System performance management directors and delivery network senior executives to facilitate and oversees the successful execution of a YNHHS performance improvement plan to include, but not limited to, all aspects of governance, data management, data analytics, progress of quality initiatives, production of salient reports and presentations that articulate the quality agenda of YNHHS. With YNHHS Medical Directors and Chief Quality Officer, s/he assumes the lead in YNHHS collaborative to reduce variation and standardize clinical care and operational effectiveness according to best practices.EEO/AA/Disability/VeteranResponsibilities
- 1. With general direction from YNHHS Executive Director Safety and Quality and in collaboration with delivery network hospitals, directs all aspects of the YNHHS safety and quality initiatives as identified in the PI Plan.
- 2. Oversees major quality functions across the system including quality, safety, data analytics, abstraction, and all aspects of data display (in collaboration with JDAT).
- 3. When appropriate to achievement of YNHHS quality and safety goals, engages outside consultants and vendors, negotiating and preparing contracts and monitoring budget and progress.
- 4. Provides internal human resource management of staff, prepares new and modifies older position descriptions, oversees timelines and quality of personnel evaluations, and is primary conduit to YNHHS Human Resources. Represents department at Vacancy Review Committee to secure approval for vacant positions. Manages, recruits, hires, administers disciplinary action and conducts job performance reviews for staff assigned to incumbent.
- 5. Develops and maintains strong working relationships with YNHHS senior management, advancing the System quality and safety agenda through the system Quality Committee and Quality Council, and advising on status of System PI plan and initiatives.
- 6. Collaborates with the Institute for Excellence in analysis and development of curricular and educational offerings to develop and maintain the YNHHS culture of safety and continuous improvement.
- 7. Enhances knowledge in the field of 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.
- 8. Management and accountability for the YNHHS Safety and Quality budget.
- 9. 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.
- 10. Completes an annual environmental scan of all available data sources and critically analyzes performance to make recommendations to Senior Leadership on organizational priorities.
- 11. Develops and participates in quality projects and facilitates the dissemination of results through interpretive presentations, automated electronic reports, and/or publications.
- 12. Directs analytic and abstraction staff as assigned. This includes management of data quality and integrity through high reliability processes.
- 13. 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.
- 14. 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.
- 15. Directs production of reports to senior leadership and collates and summarizes quarterly reports as requested by the Medical Directors.
- 16. Reports data from special projects and other quality reports to appropriate individuals, departments and committees.
- 17. 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.
- 18. 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
- 19. 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.
- 20. 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.
- 21. 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.
- 22. Mentors staff across the system in quality measurement. Maintains an exceptional work environment through effective leadership, direction, supervision, role modeling, and communication.Schedules, plans, facilitate, and conduct staff meetings.
- 23. Plans, facilitates, tracks, and modifies the organizational performance goals and action plans annually and as necessary.
- 24. 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 healthcare administration, public health or other related field required. Certified Professional in Healthcare Quality (CPHQ) required.
At least 5-7 years progressive management experience in hospitals and healthcare. Documented experience working successfully with hospital senior management and physicians. Clinical background preferred. Budget management.
Superior written and oral communication. Ability to effectively work with and motivate personnel at varying levels within an organization. Documented capacity to deliver results in a highly-matrixed work environment. Strong skills in the following areas: adaptability and flexibility, ability to learn quickly, facilitation, analysis, critical thinking, working with minimal supervision, and management of people and projects.Strong computer skills
Ability to travel between system locations on an at least weekly basis. Ability to traverse campuses.
Benchmarking (Project Management)
Complex Problem Solving