POSITION SUMMARY
The Chief Quality Officer will have overall program responsibility for TCRHCC’s hospitals Quality Services Division. The Chief Quality Officer will provide leadership and guidance in the development and measurement of TCRHCC's approach to quality, patient safety, care coordination and performance improvement for the TCRHCC health system. The Chief Quality Officer is required to demonstrate leadership and interpersonal skills to effectively work collaboratively with leadership across TCRHCC to develop strategies that support TCRHCC's quality mission and facilitate the integration of services across the entire health care continuum. The Chief Quality Officer will focus on building communication, operational and planning bridges among autonomous entities throughout TCRHCC to support and ensure the highest possible level of safety, customer service, quality, operational efficiency, and performance in partnership with the Senior Leadership Council (SLC). The Chief Quality Officer will oversee all hospital efforts to monitor and maintain compliance with all regulatory, State, Federal government, and Joint Commission on Accreditation of Healthcare Organization standards. The Chief Quality Officer must have expertise in these areas; knowledge of quality literature, theories of innovation to recommend, and the ability to implement TCRHCC's quality and safety goals. The position's focus is on continuous improvement and redesign of processes, utilization, and quality initiatives as well as the enhancement and improvement of patient satisfaction and outcomes. The position includes oversight of Care Coordination, Utilization Review, Infection Control, DME, Transport, Patient Benefits Coordinators (PBC), Risk Management, Patient Safety, Performance Improvement and Data Reporting. This position is under the supervision of the Chief Executive Officer. Priorities are provided through discussions with the SLC, the Board of Directors, and the organizational Strategic Plan.
ESSENTIAL FUNCTIONS:
- Develops, facilitates, implements, and monitors an integrated comprehensive organizational wide safety program to improve the safety of patients, visitors, and employees.
- Conduct ongoing assessments of existing quality activities and information systems, while seeking input from key managers and medical directors.
- Develop priorities and focus for quality improvement activities.
- Develop strategies to improve the efficiency of the care delivery process in a service line approach.
- Develops quality systems to monitor TCRHCC's hospitals performance; facilitates development of integrated care management strategies across TCRHCC's entities and hospitals.
- Recommends performance improvements activities related to safety, working with the corporate compliance, Risk Management, and external legal departments.
- Helps coordinate and oversee data collection and coordinates the roles of TCRHCC representatives involved in infection control, safety, risk management, and quality improvement services.
- Organizes and coordinates the TCRHCC Performance Improvement Committee; works with the committee to identify TCRHCC quality priorities and links to strategic management objectives.
- Utilizes knowledge of quality service literature, theories of innovation, and operational experience to advance quality outcomes and assists with creating a culture of safety; provides leadership for quality initiatives to facilitate the "spread of Quality Innovations" throughout TCRHCC's entities.
- Directs and facilitates TCRHCC's quality improvement activities and introduction of management systems to monitor organizational performance.
- Directs and facilitates clinical performance improvement projects directed toward improving patient care and reducing unnecessary utilization.
- Directly supervises TCRHCC's quality and patient safety staff, including time, hiring, and sequencing of all staff to meet project goals and maintain operating budget.
- Responsible for evaluating, managing, and developing staff; and ensuring all human resources policies and procedures are followed.
- Identifies needs, and develops internal capacity in TCRHCC, for:
- technical support for quality improvement activities for TCRHCC's hospital and satellites,
- assist in research, writing, and grant administration within division for the quality improvement activities, and
- Ensures data collection and intervention plan is practical and feasible, in partnership with Information Systems for implementation in the daily operations of clinical or administrative units within TCRHCC hospitals.
- Ensures consistency of approach and more effective utilization of TCRHCC's resources.
- In coordination with TCRHCC's leadership, identifies and develops opportunities for strategic partnerships with government, corporate, philanthropic, academic, or other organizations to advance the goals of quality and innovation at TCRHCC and to obtain funding for TCRHCC's programs.
- Facilitates a service excellence movement via Quality Data within TCRHCC hospitals and practice of the clinical staff.
- Oversees and directs the Customer Service program, to include managing Patient Complaints and the process which includes adherence to Joint Commission standards.
- Is responsible for the data and reports to the Quality reporting to the Board of Directors quarterly.
- Supervises and directs the Patient Advocate/ Customer Services Manager, that includes the Customer Service program (all entities;
- Identifies opportunities for training and development for medical and support staff to achieve service excellence; identifies and facilitate correction of infrastructure issues negatively affecting patients' experience; provides leadership to healthcare facilities and clinicians to improve provision of services.
- Oversees activities of Research Vetting Committee to review proposed research protocols, procedural guidelines, for TCRHCC participation.
- Provides leadership on the need for new quality or innovation programs and projects.
- Assesses financial and strategic plans for the Quality Division.
- Specifically, provides consultation and leads training sessions to give multi-disciplinary improvement teams the necessary knowledge, tools, skills, and approaches to improve specific measures of quality.
- Provides development guidance and assists in the identification, implementation, and maintenance of TCRHCC’s installing the database within the information system and electronic health record.
- Oversees the management of Accreditation processes,
- Oversees, directs, delivers, and ensures delivery of initial and ongoing reports needs for Quality measures.
- Reviews and evaluates services of the TCRHCC that are affected by medical safety/regulatory issues, identifies problems, makes recommendations for improvement, and monitors services to ensure that safety/regulatory recommendations are implemented, and the desired results are obtained.
- Proactively educates leadership and medical staff regarding regulatory issues, new statutes/guidelines, and medical safety/PI activities.
- Directs and responsible for the Infection Control program, as well as measures and reporting requirements.
- Regularly communicates PI and medical safety activities to the medical staff and engages medical staff in PI activities.
- Provides oversight for the Risk Management of the organization. This occurs through a RM Nurse working with Compliance to assure FTCA procedures are followed by the organization.
- Supervises the Durable Medical Equipment service and processes, works with the CFO in assuring revenue and reimbursements.
- Oversees the Patient Benefits Coordinators. This entails 100% assessment of beneficiary alternate resource enrollment as needed.
- Oversees and directs the organizational transport program, that includes all modes of transport, emergent and nonemergent.
- Oversees Care Coordination and Utilization Review, to include Preauthorization as needed per insurance coverage of beneficiaries.
- Assures the Utilization Review Committee is active and works in partnership with the Medical Staff.
- Leads the development of TCRHCC policies and procedures related to quality improvement/ medical safety and takes lead for Policy management.
- Provide 24/7 support and takes Administration on call for the Organization.
- Ensure proper PPE is worn at all times while on duty including but not limited to, face mask, gloves, gown, isolation gown, NIOSH-approved N95 filtering facepiece respirator or higher, if available), and eye or face shield.
- Complete all donning and doffing tasks in a safe acceptable method and discard of used PPE accordingly. (see CDC website for most current updates)
- Complete task training for all routine cleaning and decontamination processes for all surfaces contaminated by a communicable disease to ensure a high level of patient, visitor, employee and external customer satisfaction.
- Willingly performs other related duties as assigned.
MENTAL AND PHYSICAL EFFORT
The physical and mental demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
Physical:
Must be able to stand, walk, and sit for long periods of time. Must be able to lift up to 20 lbs. Must be able to distinguish numbers, letters, and colors. Must be able to see, hear, and talk.
Mental:
Must be able to prioritize and use good judgment. Must have critical thinking skills to problem solve and plan, identify and question issues and information in order to make appropriate assumptions, inferences, implications, and decisions. Employee must be able to communicate with staff, providers, senior leaders, legal counsel, and external entities in a manner complementary to TCRHCC.
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