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Overview

At SCA Health, we believe health care is about people – the patients we serve, the physicians we support and the teammates who push us forward. Behind every successful facility, procedure or innovation is a team of 15,000+ professionals working together, learning from each other and living out the mission, vision and values that define our organization.

As part of Optum, SCA Health is redefining specialty care by developing more accessible, patient-centered practice solutions for a network of more than 370 ambulatory surgical centers, over 400 specialty physician practice clinics and numerous labs and surgical hospitals. Our work spans a broad spectrum of services, all designed to support physicians, health systems and employers in delivering efficient, value-based care to patients without compromising quality or autonomy.

What sets SCA Health apart isn’t just what we do, it’s how we do it. Each decision we make is rooted in seven core values:

+ Clinical quality

+ Integrity

+ Service excellence

+ Teamwork

+ Accountability

+ Continuous improvement

+ Inclusion

Our values aren’t empty words – they inform our attitudes, actions and culture. At SCA Health, your work directly impacts patients, physicians and communities. Here, you’ll find opportunities to build your career alongside a team that values your expertise, invests in your success, and shares a common mission to care for patients, serve physicians and improve health care in America.

At SCA Health, we offer a comprehensive benefits package to support your health, well-being, and financial future. Our offerings include medical, dental, and vision coverage, 401k plan with company match, paid time off, life and disability insurance, and more. Click here (https://careers.sca.health/why-sca) to learn more about our benefits.

Your ideas should inspire change. If you join our team, they will.

Responsibilities

The Director of Quality & Patient Safety provides leadership support and direction for the development, implementation and ongoing monitoring of organizational regulatory and accreditation programs and processes, including general oversight of required reporting of quality data to external agencies. In addition, works closely with the VP of Quality and Patient Safety to support all aspects of quality, patient safety, performance improvement and high reliability efforts. The Director champions a culture of quality and patient safety through role modeling, teaching, and mentoring and promotes a high reliability organization through development, endorsement, and/or deployment of consistent, evidenced based tools and resources. The Director will work in concert with SCAH Clinical Services, operational leadership and Support Services both strategically and tactically, collaborating with a variety of professional organizations while serving the greater SCAH Community.

Maintain knowledge and oversight of compliance with state and federal regulations, accreditation standards, and quality related best practices for ambulatory surgery centers and surgical hospitals including:

+ Clinical, environmental safety regulations, SCA policies, and evidenced based practices

+ Quality Improvement and risk mitigation methodologies, tools, and techniques

+ Process for auditing clinical operations at a local level to assess for compliance

+ Industry trends and legislative updates involving quality, patient safety, and/or compliance with regulatory and accreditation activities

+ State, federal, and accreditation quality reporting programs, including timelines, reporting methodologies, etc.

+ SCA Quality Improvement and Patient Safety Program to include associated programs such as Risk Management, Environment of Care, Infection Prevention, Medication Management, Human Resource, Medical Staff, Governance, etc. related standards, guidelines and recommended practices

Development, coordination, and communication of strategic planning initiatives, key performance indicators, needs assessment and evaluation of the organization’s quality, patient safety, and accreditation and regulatory programs to facility and operations leaders and SCA Support Services Departments as applicable:

+ Provides leadership, develops, and recommends new methods to comply with Quality and Performance Improvement standards and as applicable with Infection Control, Risk Management, Patient Safety, Peer Review, etc. Monitors the measured outcomes of organization-wide clinical care activities, identifies opportunities for improvement, and leads clinical improvement activities

+ Recommend, develop, and measure key performance indicators (KPIs) relevant to quality, patient safety, accreditation and regulatory compliance and impact on SCA vitals, goals, strategic plan, etc.

+ Ensure program alignment with annual goals and strategic initiatives for SCA and the Clinical Services Department

Provide collaboration, mentorship, leadership, communication, and/or consultation regarding patient safety, accreditation and regulatory initiatives to Facility, Operations, Clinical, and Support Services department leaders including:

+ Collaborates with other departments such as legal, regulatory compliance, human resources, etc. to ensure compliance with relevant standards of performance, including federal, state, and accrediting organizations

+ Maintain regular communication with SCA Clinical Services Department, Operations Leaders, and Support Services lanes as appropriate on progress as it relates to accreditation and/or regulatory standards, goals, objectives, and plan of corrections

+ Work closely with members of the Clinical Services department to ensure awareness of facility regulatory and accreditation performance in order to identify possible organizational education/training opportunities

+ Monitor, analyze and communicate activities, trends, results and recommendations related to quality, accreditation, and regulatory activities and findings to include changes in regulations, standards, etc. to organizational leadership and the greater SCA Community

+ Assist and mentor facility leaders, facility quality coordinators, and regional quality leaders with planning, implementing, and maintaining compliance with accreditation and regulatory standards and SCA policies and procedures using SCA tools & resources

+ Provide guidance and support to complete proactive risk assessments, periodic performance reviews, and/or plan of corrections

Responsible for supervision, oversight and monitoring of the organization’s compliance with state and federal requirements and accreditation/certification standards through agencies such as The Joint Commission or AAAHC. Establishes a quality assurance program and system to ensure procedures and protocols are consistent with requirements to achieve constant readiness for site visits and surveys:

+ Performs risk assessments to proactively identify potential and actual risks to safety, identifies underlying causes and makes improvements to reduce risks

+ Assesses compliance with accreditation standards and regulations to determine areas of risk and vulnerability

+ Develops and monitors actions to address individual and aggregate trends to ensure adherence to regulatory and accreditation compliances. Evaluates effectiveness of corrective actions for identified problems and continuous quality improvement activities

Directs and coordinates quality, accreditation, and regulatory initiatives for the organization; serves as the organizational liaison with accrediting bodies and other pertinent regulatory agencies:

+ Network and build relationships with internal and external resources regarding quality, accreditation, and regulatory opportunities

+ Serves as a representative for external interactions with accrediting and regulatory bodies

+ Leads and participates in relevant internal and/or external boards, committees, etc. as applicable

+ Participates in internal and external speaking and training engagements and webinars

Ensure SCA policy and procedures comply with regulatory and accreditation standards and provide consultative services as appropriate:

+ Develops, reviews annually at minimum, and updates SCA policies and procedures to remain in compliance with current evidenced based practices, regulatory and accreditation standards, etc.

+ Ensure policy templates developed by internal and/or external agencies available for facilities to utilize are compliant with current evidenced based practices, regulatory and accreditation standards

Utilize software and/or online applications to deploy, store, track, report, etc. SCA policy and procedures, regulatory and accreditation surveys, and SCA on-site risk assessments:

+ Management of accreditation and regulatory standard compliance related tools, resources, and programs in the Clinical Services home page area with updates as needed on an ongoing basis

+ Management and oversight of clinical content library related to accreditation and regulatory activities to ensure accuracy and relevance on an ongoing basis

+ Development, endorsement, and/or management of patient safety, regulatory and accreditation, etc. compliance related business intelligence tools and dashboards

Develop and/or endorse programs, tools, and resources which optimize patient safety and reduce the likelihood of medical/health care errors:

+ Develop, update, and maintain patient safety, quality, and/or clinical compliance programs, play books, tool kits, etc. on an ongoing basis for clinical staff positions working in the peri-operative settings

Qualifications

Education: A Bachelors Degree in Nursing is required.

Experience:

+ Minimum of five years of experience in the Ambulatory Surgery Center and/or Hospital operations

+ A minimum of five years of quality, accreditation and improvement experience including a thorough understanding of QI processes, tools and techniques, quality measurement and reporting, accreditation standards, CMS Conditions of Participation/Coverage and State regulations, root cause analysis and preventive risk management strategies

+ Experience leading and facilitating performance improvement teams within the healthcare environment.

Requirements:

+ Experience and proficient in use of Microsoft products (Office 365, One-Drive, Share Point, Yammer, Word, Excel, and Power Point), use of dashboards and Web-based clinical platforms i.e. policy and procedure platform, risk management platform, web-based accreditation sites, etc.

+ Continues personal and professional development through active participation in and contribution to industry conferences, meeting presentations, journal publication and educational offerings. Examples include but are not limited to ASCA and associated state groups, AHRQ, AORN, ASPAN, AAMI, AAAHC, TJC, CMS, ASCQC, APIC, CDC, OSHA, IHI, WHO, and other similar organizations

+ Experience and understanding of patient care delivery to include staff member roles in the peri-operative setting

+ Competent and experienced with regulatory and accreditation standards and survey readiness process

+ Experience and proficient in use of accreditation and regulatory related key performance indicators (KPIs) to measure performance and ability to execute strategies based on findings

+ Experience developing and/or revising policies and procedures to reflect evidence, industry, and/or needs of the organization

+ Excellent interpersonal skills, with the ability to communicate effectively and concisely both verbally and in writing with individuals and groups at various levels and various disciplines, including with the Sr. Executive team.

Licensure & Certification:

+ Current/Ac tive Registered Nurse license, in good standing

+ CPHQ preferred but not required

USD $150,000.00/Yr. USD $180,000.00/Yr.