Job Summary Director, System Quality
Provides accountability for quality initiatives across the East region by setting priorities and organizing work, obtaining appropriate input internally and externally, setting agendas, developing quality standards and implementing best practices.
Collaborates with executives at all levels, including clinicians and clinical leaders, on quality strategies and procedures. Develops content and presents to the Board of Director's Quality & Safety Committee on a regular basis.
Partners with the regional and site clinical teams, responsible for ensuring reporting and data submission compliance to CMS, BCBSM, The Joint Commission, NHSN, and any other external quality entity.
Manages and coordinates system clinical data abstraction staff for Centers for Medicare & Medicaid Services (CMS) / The Joint Commission (TJC) Core Measures reporting. Manages and coordinates system clinical data abstraction staff for Blue Cross Blue Shield of Michigan Collaborative Quality Initiative (BCBSM CQI) and other national registries. Collaborates with Information Technology to submit data for CMS electronic clinical quality measures (eCQM). Ensures data submission, through chosen vendors, to CMS, TJC, and other regulatory agencies, for the health system. In compliance with external and internal guidelines, ensures compliance of all data submission through inter-rater reliability and collaborative audits. Summarizes external quality measure performance, identifying areas of opportunity and success, presenting findings to executive and clinical leadership in a succinct manner. Management scope includes manager subordinates and their nurse abstractor director reports; responsible for hiring and termination decisions, along with resolving employee grievances.
#CH-LI
Essential Functions - Director, System Quality
- Lead, motivate, and utilize business judgment to oversee quality initiatives for the East with responsibility to move the quality objectives of the region forward.
- Implements and oversees quality improvement plans to ensure maximum performance.
- Provides leadership and expertise in problem solving to evaluate the improvement of recommended strategies, programs, and/or projects to coordinate care, improve quality, oversee process improvement, and improve customer satisfaction.
- Direct and assure data submission to CMS and the Joint Commission, and other regulatory agencies.
- Instrumental in supporting regulatory processes such as validation and accreditation; TJC and CMS standards.
- Partners with Accreditation to facilitate Joint Commission readiness and survey activities for the East region. Partners to ensure adequate responses to the Joint Commission regarding complaints/grievances relative to quality-of-care issues.
- Use process improvement tools and techniques to successfully impact clinical operations and outcomes demonstrating quality.
- Manages reporting and data analytics for quality-based activities.
- Monitors and reports Metrics that Matter and Quality Matrix data to administrative and regional leadership; analyzes quality outcomes and provides direction on improving quality outcomes and provides direction on improving quality outcomes.
- Maintains oversight of progress on external reporting metrics for programs such as Value Based Purchasing, Hospital Acquired Conditions, Hospital Readmission Reduction Program amongst others.
- Works towards improvement in reputational programs such as US News and World Report, Leapfrog, CMS Stars.
- Administrative oversight and responsibility for operational and budget performance, including development and monitoring of financial goals, variance analysis, monitoring of key performance indicators, operating statistics and implementation of performance improvement initiatives.
- Provides all necessary assistance and support to the regional vice president as assigned.
Qualifications - Director, System Quality
- Required Bachelor's Degree in Healthcare Administration, Nursing, or related field
- Preferred Master's Degree
- 10 years of relevant experience. Minimum ten years related work experience in quality Required
- 5 years of relevant experience. Minimum 5 years’ experience in management. Required
- Experience in interpreting data sets and performing statistical analysis where needed. Required
- LIC-Registered Nurse (RN) - STATE_MI State of Michigan Upon Hire preferred
Physical Demands - Director, System Quality
- Pallet to Waist (6" from floor) > 5 lbs: Seldom up to 10 lbs
- Waist to Waist > 5 lbs: Seldom up to 10 lbs
- Waist to Chest (below shoulder) > 5 lbs: Seldom up to 10 lbs
- Waist to Overhead > 5 lbs: Seldom up to 10 lbs
- Bilateral Carry > 5 lbs: Seldom up to 10 lbs
- Unilateral Carry > 5 lbs: Seldom up to 10 lbs
- Pushing Force > 5 lbs: Seldom up to 10 lbs
- Pulling Force > 5 lbs: Seldom up to 10 lbs
- Sitting: Frequently
- Standing: Occasionally
- Walking: Occasionally
- Forward Bend - Standing: Seldom
- Forward Bend - Sitting: Occasionally
- Trunk Rotation - Standing: Seldom
- Trunk Rotation - Sitting: Occasionally
- Reach - Above Shoulder: Seldom
- Reach - at Shoulder or Below: Seldom
- Handling: Occasionally
- Forceful Grip > 5 lbs: Seldom
- Forceful Pinch > 2 lbs: Seldom
- Finger/Hand Dexterity: Frequently
- Visual Acuity ¹
[None = No; Seldom = Yes]: Seldom
Primary Location
SITE - Beaumont Service Center - 26901 Beaumont Blvd
Department Name
Quality, Safety and Experience - CH East
Employment Type
Full time
Shift
Day (United States of America)
Weekly Scheduled Hours
40
Hours of Work
8:00 a.m. to 5:00 p.m.
Days Worked
Monday through Friday
Weekend Frequency
N/A
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