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Department/Unit:

Quality Management

Work Shift:

Day (United States of America)

Salary Range:

$133,724.95 - $213,959.93

This senior supervisory position will lead and oversee all clinical, budgetary, regulatory, analytical and supervisory operations of the Albany Medical Center Quality Management and Accreditation department. This will be through the collection and validation of data submitted to all external quality registries spread throughout Albany Medical Center and the Albany Med Health System that are facilitated within the quality management department. This includes DNV compliance, Adult NSQIP, Pediatric NSQIP, NYSDOH Adult CT Surg, NYSDOH Pediatric CT Surg, NYSDOH PCI, STS/ACC TVT, STS Adult CT Surg, STS Congenital, STS Thoracic, GWTG-CAD, GWTG-HF, GWTG-Stroke, NCDR LAAO, CARES, ELSO. Responsibilities include financial decisions, personnel types and resource assignment decisions, consolidation of software and IS support systems, facilitation of contract negotiations, interface with Federal and State agencies, and partnering with system contacts or physician leaders for standardizing clinical abstraction techniques and definitions. The AVP of Accreditation and Quality will also be responsible for overseeing certification implementation and directing activities that support the institution's ability to achieve and remain a successfully accredited health care organization that is continuously ready for patients every day. For all other programs, including Disease Specific Certifications and Laboratory surveys, the director will serve as a resource and consultant to the survey coordinators acting as a liaison between the organization and its accreditation or regulatory bodies, and as an expert in continuous improvement processes.

Essential Duties and Responsibilities

+ Strategic Planning Responsibilities

+ Liaises as necessary with the Quality Management departments of Saratoga Hospital, Glens Falls Hospital and Columbia Memorial Hospital to collaborate on areas of overlap, strategic planning for resources and quality- related system activity

+ Serves as a member of the Albany Med Health System Quality Council. Work in collaboration with quality directors at affiliate institutions, manage and facilitate quality focused system workgroups and disseminate system quality decisions to institutional stakeholders.

+ Supports Albany Med's patient safety mission by liaising with Culture of Safety and Patient Safety Committee.

+ Assists the Associate Medical Director of Quality Management in developing the Performance Improvement and Patient Safety plan

+ Acts as a key facilitator with the Associate Medical Director of Quality in the development of annual quality goals and measurement processes for each major service and department as it relates to clinical outcomes.

+ Provides guidance in data collection and analysis approaches at hospital and system levels for programs such as AMC CARES

+ Represents Albany Medical Center through involvement in quality-oriented activities in the community and professionally at national meetings.

+ Along with the Associate Medical Director of Quality represents Quality Management in senior leadership forums, work groups and committees.

+ Technical Responsibilities

+ Liaises with Albany Med Analytics to ensure timely and complete collection and submission of all Federal and NYS-mandated quality and safety Core Measures and other regulatory metrics as required

+ Serves as facilitator for 3M360 CDI, Coding, and Quality collaboration to ensure appropriate assignment of patient safety indicators and hospital acquired conditions are appropriately assigned.

+ Serves as Administrator for Press Ganey program, partnering with the Chief Patient Experience Officer and Chief Nursing Officer to ensure enhanced utilization of all program components including patient survey/patient experience feedback, HCAHPS, OASCAHPS, NDNQI, Quality Metrics facilitation and management within the PG quality program.

+ Interfaces with all outside chart abstraction vendors including contract negotiation, training, IS interface facilitation, and oversight of work in progress and completed

+ Oversees the collection and analysis of quality data for use by Albany Medical College. Supports the academic mission through collaboration with students, residents and clinical colleagues using quality data generated through various quality programs and registries for academic, scholarly, and research purposes.

+ Administrator for Vizient CBD tool. Utilization/facilitation of the program to enhance quality insight for the institution.

+ Along with the Associate Medical Director Quality collaborates with Value Based Care team in payer- contracting negotiations for selected measures and targets with considerable financial impact.

+ Meets all CMS, State, DNV requirements for quality-related measures. Ensures quality systems are designed to meet specific regulatory requirements of the CMS and Joint Commission as it relates to performance improvement and reporting of results to executive level.

+ Directly responsible for use and maintenance of hospital-wide systems related to quality improvement such as: Press Ganey patient experience products and services, Vizient Clinical Database (CDB) and related services, and mortality and morbidity collection platforms

+ Collaborates with data analytics and informatics to navigate required information portals for submitting quality related data to CMS and DNV, such as for VBP, IPPS, IQR, NYSDOH Sepsis care, TJC core measures and others.

+ Maintains the current cadre of 14+ clinical registries while seeking opportunities to further consolidate registry resources under the Quality Management Department. Ensures data is reported on a timely basis and has been validated for accuracy against registry rules.

+ Ensures use of statistical process control methodology or other statistical applications to properly support an effective quality program.

+ Manages quality-related information sets, databases and resources in order to support the department, quality improvement teams, Risk Management, Finance, Payer Contracting, CMS value -based purchasing, regulatory inquires and other customers.

+ Supervises the comprehensive collection, Morbidity and Mortality case reviews organization, distribution to clinical services and archiving, of Morbidity and Mortality case reviews

+ Supervises the accreditation team to ensure compliance with all DNV requirements

+ Oversees the development and implementation of the Continuous Patient Readiness plan

+ Directs all organizational Continuous Patient Readiness Activities

+ Leads and coordinates formal accreditation and certification on-site surveys, acting as the survey coordinator

+ Leadership Responsibilities

+ Supports Albany Med's Quality Improvement Teams by supplying data and data analyses on request, organizing Team schedules and overseeing the operation of the Albany Med Quality Committee

+ Oversees all matters related to the recruitment, retention, training, work assignment, daily supervision and annual review of the Accreditation and Quality Management staff

+ Directs departmental operations including responsibility for all staff hiring, annual review of competencies, budgeting, and strategic planning. Mentors staff with a focus on personal development through the use of department-suggested tools, techniques and data sources.

+ Oversees the training of administrative and nursing resources responsible for collection and use of the information. Serves as an effective coach by guiding teams through incremental improvement or reengineering process, facilitating use of appropriate models, tools, and techniques

Qualifications

+ Master's Degree Graduate-level Degree (Masters, PhD, DNP, or equivalent) completed or in progress - required

+ Education in inferential statistics and application in performance improvement - preferred

+ 3+ years experience in quality management or accreditation to include work on quality, safety improvement, and regulatory compliance - required

+ 3+ years of clinical experience in healthcare delivery - required

+ 5+ years management experience with >3 or more direct reports - required

+ 5+ years experience in a leadership role applying performance improvement concepts and change-management tools - required

+ Demonstrated experience managing ever-changing local, federal and/ or state Quality Program measures, expertly meeting requirements, tracking success and reporting results at executive level. - preferred

+ Experience applying clinical registry findings through directly working with interdisciplinary teams to produce improved, measurable results - preferred

+ Experience utilizing platforms housing risk adjusted data used in modeling, trending/target setting and defining outcomes - preferred

+ Experience in designing and maintaining a hospital or system level patient experience assessment and reporting program - preferred

+ Past or current active participation in quality-related societies or area organizations - preferred

+ Demonstrated ability to design, implement, document and maintain a system- level Quality Program meeting regulatory requirements and internal needs for clinical performance improvement in all major services and departments

+ Knowledge of all CMS programs, CMS COPs, DNV requirements, manually abstracted and electronic clinical quality "core measures".

+ Knowledge of federal, state and regulatory requirements for hospital quality- related programs

+ Knowledge of public facing quality ratings such as Leapfrog and CMS star ratings

+ Ability to read and analyze documents such as safety rules and procedure manuals.

+ Ability to document on established forms.

+ Ability to communicate cooperatively and effectively to clients and others.

+ Ability to listen well, to engage in interactive dialogues with others, and to facilitate communication among groups.

+ Ability to seek the input of others to achieve consensus.

+ Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.

+ Ability to compute rate, ratio, and percent. Use of algebraic equations to determine or understand documented modeling.

+ Utilize knowledge of experimental design and statistics for reporting program evaluation data.

+ Ability and to perform the job in adherence to the highest standards of ethical conduct as defined by AMC and the tenets of the profession.

+ Ability to be accurate in such matters as record keeping, and to use good judgment when performing the functions of the job or when interacting with others. The individual is accountable for own performance. Demonstrate principles of conflict resolution and promote consensus building.

+ Ability to promote and assist with the creation of AMC's policies, procedures and practices. Delegates and coordinates work assignments with support staff.

+ Ability to problem solve.

+ Ability to evaluate projects, breaking down into manageable size to define steps. Must be able to research, accumulate a body of work, support and defend a decision after carefully reasoning through options, evaluating effectiveness and plausibility against work flows, partnering with leadership and reviewing common practices nationally.

+ Ability to organize and present thoughts logically

+ Strong interpersonal communication, organization, and planning skills

+ Ability to problem-solve, exercise judgment, and make decisions

+ Ability to manage a department

+ Skills in public speaking

+ Ability to lead and facilitate teams

+ Ability to recognize and manage group dynamics

+ Ability to work with others to accomplish goals and solve problems

+ Ability to provide training in QM concepts and tools

+ Advanced skills in the use of QM tools and techniques

+ Skill with computer technology

+ Skill in complex data analysis and synthesis

+ Experience in the use of statistics

Equivalent combination of relevant education and experience may be substituted as appropriate.Physical Demands

+ Standing - Occasionally

+ Walking - Occasionally

+ Sitting - Constantly

+ Lifting - Rarely

+ Carrying - Rarely

+ Pushing - Rarely

+ Pulling - Rarely

+ Climbing - Rarely

+ Balancing - Rarely

+ Stooping - Rarely

+ Kneeling - Rarely

+ Crouching - Rarely

+ Crawling - Rarely

+ Reaching - Rarely

+ Handling - Occasionally

+ Grasping - Occasionally

+ Feeling - Rarely

+ Talking - Constantly

+ Hearing - Constantly

+ Repetitive Motions - Frequently

+ Eye/Hand/Foot Coordination - Frequently

Working Conditions

+ Extreme cold - Rarely

+ Extreme heat - Rarely

+ Humidity - Rarely

+ Wet - Rarely

+ Noise - Occasionally

+ Hazards - Rarely

+ Temperature Change - Rarely

+ Atmospheric Conditions - Rarely

+ Vibration - Rarely

Thank you for your interest in Albany Medical Center!Albany Medical Center is an equal opportunity employer.This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that:Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Medical Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.

Thank you for your interest in Albany Medical Center!​

Albany Medical is an equal opportunity employer.

This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that:

Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.