Manager Quality &Accreditation

Summary

Summary

Quality - Collaborates and strategizes with the Director Quality in building cohesive quality accreditation specialist (QAS) and accreditation teams. Communicates changes, updates, and expectations to the team timely and effectively. Serves as liaison for the QAS and accreditation specialists to the Director, VP and CQO. Serves as a catalyst in bringing together quality and patient outcomes. Leads personnel in a direction that fulfills the mission and goals of Parkview Health. Manages conflicts by facilitation, coaching and mentoring. Uses analytical skills in order to interpret data, problem solve, and present data to various audiences. Interprets regulatory standards and assesses the level of impact to the system. Uses quality improvement techniques and tools to develop and implement detailed system-wide action plans. Coordinates day-to-day operations through standard work, as well as evaluates, oversees and validates quality and accreditation projects. Acts as a role model, orients, coaches and mentors staff, as well as serving as a resource and contact person to staff and to others within and outside of the organization. Responsible for completing regular performance evaluations. Ensures that all department standards are maintained as well as encourages a team environment and maintains positive customer service. Responsible to monitor and maintain approved department budget. Participates in strategic plan tactics, regulatory compliance, data management/system management, policy and procedure development and review, and service line participation/support.

Quality Resources - Acts as the primary resource for internal and external safety, quality and regulatory educational needs. Responsible for the development, coordination and oversight of the orientation, training, competency & proficiency assessments of the Quality Management (QM) staff. Oversees program and standard work for education and training of new QM coworkers and ongoing education and professional growth of QM staff. Identifies resources needed for departmental QM education efforts. This includes working with other QM Leaders to assure we have the necessary resources and a standard approach to all training.

Accreditation, Certification & Standards Compliance – Manages and leads QM accreditation staff. Serves as operational lead for the PH System Accreditation Collaborative. Serves as a subject-matter expert in regulatory and accreditation processes. Assists the Director in managing, coordinating, standardizing evaluating and enhancing all systems and processes related to Parkview Hospitals licensure/accreditation/certification. Maintains knowledge of current trends within ISDH, The Joint Commission and CMS standards and survey processes. Assists to optimize activities of QM team members by ensuring that issues and actions are understood and standardized, changes in requirements and information are shared, and needs/resources of the team members are communicated. Guides and oversees analysis of survey findings and response to citations. Collaborates in compliance/quality assessments, action planning and performance improvement activities. Assures process for standardization, review and approval of action plans for regulatory agencies under Quality Management’s purview. Manages and leads Policy/Procedure staff. Assures standardized and optimized processes for the policy/procedure and nursing skills/practice (Mosby’s/Elsevier) platforms. Assures compliance related to medical staff approved protocols. Enhances and manages relationships of stakeholders within the policy/procedure, protocols and nursing practice platforms.

Education

Bachelor's degree in nursing or health related field required. If Bachelor's degree is in Nursing, must have a BSN from accredited program. Master's degree in nursing, education or health administration preferred.

Licensure/Certification

Must have a valid Indiana RN licensure, if degree is in nursing. CPHQ certification required or obtained within 12 months of hire. HACP certification, educator and project management experience preferred.

Experience

Minimum of five years in a lead, supervisory and/or educational role. Experience in healthcare quality, regulatory compliance, data analysis and reporting preferred.

Other Qualifications

Demonstrates strong organizational skills, including accuracy and attention to detail. Proven ability to lead personnel in a direction that fulfills the mission and goals of Parkview Health, as well as the ability to plan, implement and evaluate change. Excellent written and verbal communication skills. Proficient in Microsoft computer-based programs. Working knowledge of data warehousing, disease registries, and quality report interpretation, knowledge of EPIC preferred. Knowledge of Value based measures, Meaningful Use, PQRS, NQF etc. measures desired. Must possess strong customer service skills and coworker development skills. Demonstrated ability to work collaboratively and effectively with physicians and care teams. Must possess strong critical thinking skills. Ability to lead physicians and peers in a positive, collaborative and professional manner. Demonstrates knowledge through education or experience in supervision/management. Must have skills/knowledge related to the position's technical and clinical setting including working knowledge of regulatory standards/requirements including IDOH, CMS and The Joint Commission.