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Employment Type:

Full time

Shift:

Day Shift

Description:

Manager Performance Excellence and Accreditation - FT Days at St Peters Hospital

POSITION PURPOSE

Provides leadership and expertise in the areas of accreditation and regulatory compliance, quality and patient safety standards as it relates to associates, staff, inpatient units and outpatient services of Acute Care Albany-St. Peters Health Partners. Collaborates with leadership to direct and coordinate the planning, implementation and evaluation of clinical process related to regulatory compliance. Leverages clinical information technology, process design, change management and evidence to ensure ongoing survey readiness and compliance with accreditation regulations and standards. In addition, works on specific initiatives related to external certification or recognition as reflected in the organization’s strategic quality and safety priorities. Assures the organization’s ongoing survey readiness.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

+ Supervises Performance Excellence Consultants who lead or facilitate quality improvement activities, provide project management, data analysis and measurement of outcomes, document and report the results and accomplishments of quality improvement initiatives in concert with other team leaders.

+ Manages and directs the implementation of organizational regulatory compliance activities across all areas of Acute Care Albany, partnering with unit and program managers and leaders as appropriate.

+ Leads organization pre-survey activities (preparation of documents for surveyor review while on site).

+ Coordinates organizational response during CMS, Joint Commission surveys, State Licensing, and third-party on-site surveys.

+ Communicates survey results and assists with development of action plans and survey response in accordance with regulatory timelines.

+ Assures completion and effectiveness of action plan and reports any required measurement in a timely fashion.

+ Manages the daily functions of the Accreditation Software, Joint Commission extranet and CMS Quality Net websites to assure compliance with regulatory reporting requirements.

+ Works with organizational leadership to identify regulatory gaps and works to develop plans to address these gaps and issues.

+ Utilizes performance improvement methodologies and change management strategies to address identified compliance gaps in regulations and standards.

+ Works with organizational leadership to evaluate the effectiveness of regulatory activities.

+ Strategizes with senior leadership to develop organizational response to new regulations and standards with health system leadership.

+ Partners with a variety of departments across the health system to promote standardization and continuity of patient care activities to meet regulatory and patient safety requirements.

+ Works with the Patient Safety, Quality Improvement, and Risk Services staff to develop, design and maintain data trend reports.

+ Verifies accuracy and integrity of data that is publicly reported, prior to publication by external agencies.Develops and oversees a system of ongoing organizational tracers to identify quality, safety, and regulatory issues and assure continual survey readiness.

+ Interacts with external consultants to improve organizational survey readiness.

+ Proactively monitors proposed changes in regulatory requirements, and other external reporting agencies and shares information with applicable staff, leading the development of action plans to assure compliance when proposed changes become effective.

+ Participates in hospital and system quality and safety committees and teams.

+ Serves as a resource/consultant to all departments related to quality, safety, accreditation and regulatory issues.

+ Leads task forces and teams charged with improving regulatory and accreditation compliance. Serves on system-wide committees directly related to regulatory and accreditation requirements.

+ Maintains knowledge of current trends and developments in the fields of accreditation and regulatory standards/compliance.

+ Networks with Trinity System Office and other accreditation professionals. Acts as a liaison to Trinity Health Accreditation Liaison workgroup.

+ Willing to learn new skills and tools necessary to facilitate compliance, quality and safety activities.

+ Maintains good rapport and cooperative relationships. Approaches conflict in a constructive manner.

+ Helps to identify problems, offer solutions, and participate in their resolution.

+ Maintains the confidentiality of information acquired pertaining to patient, physicians and employees.

+ Discuss patient and hospital information only among appropriate personnel in appropriately private places.

+ Behaves in accordance with the Mission, Vision and Core Values of SPHP.

+ Assumes responsibilities for performance of job duties in the safest possible manner, to assure personal safety and that of coworkers, and to report all preventable hazards and unsafe practices immediately to management.

OTHER FUNCTIONS AND RESPONSIBILITIES

Participates actively with leadership in recommending decisions regarding practice issues and material resources. Participates in hospital and medical staff committees and task forces related to quality and cost factors of patient care delivery, quality management or accreditation factors as necessary. Designs, teaches and evaluates education programs for accreditation and regulatory issues as needed.

_Performs other duties as assigned._

REQUIRED EDUCATION, EXPERIENCE AND CERTIFICATION/LICENSURE

+ Education: Bachelor’s degree in Nursing, Pharmacy or other clinical or health care systems background with a master’s degree in a healthcare or healthcare-related field preferred.

+ Lean training required. Six Sigma training at a green belt or higher preferred.

+ Experience: Minimum of two to three years progressively more responsible related work experience in accreditation and regulatory activities. Experience with, and understanding of key functions of hospital and medical staff departments or services

+ Previous Joint Commission and Centers for Medicaid and Medicare accreditation experience preferred, with a minimum of 5 years of leadership experience within a healthcare delivery system with an in depth understanding of regulatory requirements and healthcare operations. Certification as a Joint Commission Professional (CJCP) preferred.

REQUIRED SKILLS AND ABILITIES

Advanced interpersonal skills necessary to effectively communicate complex theoretical and technical concepts effectively with a wide variety of individuals. Advanced analytical and computer skills in order to manage project work and data. Advanced analytical skills necessary to develop sound recommendations and assist in implementing improved delivery of care systems, policies and procedures, evaluating clinical practice outcomes and developing educational programs. Ability to work with and lead multidisciplinary teams in initiatives to facilitate implementation and measurement activities. Ability to integrate information across myriad settings with the goal of standardization (when appropriate), simplification, and reduction of non-value-added work and steps.

Salary Range: $39.45hr-58.20hr

Our Commitment to Diversity and Inclusion

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran