Job Posting
Director of Quality and Compliance RN - Main Campus and all locations of SLHD
The Director of Quality and Compliance is a Senior Leader for South Lincoln Hospital District. This position is responsible for the Quality, Compliance, and Risk Management programs for South Lincoln Hospital District. Serving as a subject matter expert, this position establishes, maintains, and strengthens organization-wide Quality and Compliance structure and reporting. This position consults and advises each department leader in their responsibility to fully own Quality and Compliance efforts for the areas departments, teams, and functions they lead. This role will assist each leader to be perpetually “survey ready” and will provide support and training to teams, as requested by the leader, in order to maintain this readiness. The successful candidate for this position will provide recommendations to Senior Leaders regarding holding leaders accountable for Quality, Compliance, and risk management challenges. Though not individually responsible to accomplish the day-to-day functions in each department related to quality and compliance, this position acts as the “golden thread” unifying the entire organization in these endeavors and ensures that turnover in leadership positions does not negatively affect the quality and compliance of the affected department(s). In addition to supervising all personnel in the Quality department, this position directly supervises two functions and the personnel associated with them: 1) Patient Experience; 2) Employee Heath and Infection Control.
Education, Certifications and/or Experience
Required:
• 2+ years of documented healthcare leadership experience including quality and compliance initiatives
• Documented professional success in decision making, change management, performance improvement, quality, patient safety, and data analysis in a healthcare setting
Preferred:
• Registered Nurse (RN) with a current license in the state of Wyoming or the ability to obtain such within sixty days of the beginning of employment.
• Bachelor’s Degree in Nursing, Risk Management, Finance, Business Management, or other-related field
• 5+ years of experience leading quality and compliance initiatives in a healthcare setting.
• 2+ years of experience in a Senior Leader or C-suite executive role in a healthcare setting.
• Broad clinical experience in acute, emergency, nursing home, and clinic healthcare settings
Desired
• Master’s Degree in Nursing, Risk Management, Finance, Business Management, or other-related field
• Formal training or certification in continuous process improvement, Lean, and/or Six Sigma
• 5+ years of experience in a Senior Leader or C-suite executive role in a healthcare setting.
• 10+ years of experience leading quality and compliance initiatives in a healthcare setting.
Responsibilities / Functional Job Description
General: Performance Expectations
1. Responsible - works independently, in a safe and appropriate manner. Demonstrates both problem-solving and problem-prevention skills.
2. Sensitive - displays sensitivity to the needs of patients and co-workers. Demonstrates good communications skills and empathy.
3. Timely - recognizes time as a customer's most valuable resource and responds promptly to patients' and co-workers' needs.
4. Accurate - works carefully and precisely, with attention to detail.
5. Coordinated - organizes and delivers service in the proper order. Displays good organization skills and utilizes resources wisely.
6. Thorough - meets all the requirements of his/her position. Is able to evaluate and follow up on his/her services.
General: Standards of Behavior
1. Demonstrates a commitment to living the SLHD standards of behavior through exemplifying in action, a commitment to the values of SLHD, namely:
2. Innovation – continually seeking the latest advances in cost effective healthcare and customer service.
3. Compassion – concern for the individual, empathy for the situation, action to provide service
4. Integrity – doing the right thing; always.
5. Community – supporting, giving and acting to improve where we live, serve, and work.
6. Passion for Healthcare – fervently, avidly, and zealously seeking the improvement of human health
7. Displays this commitment to the standards of behavior through actions and words, by demonstrating the following behavior traits:
8. Adaptability – Responding resourcefully to changes in direction, priorities, schedules, approaches and responsibilities for the good of everyone. Maintaining a positive attitude when faced with a difficult or challenging situation and providing an uplifting and realistic outlook on the opportunities the future may present.
9. Communication – Listening attentively and seeking clarification, being friendly in words and actions, responding to others in a timely manner to ensure satisfaction, comfort and quality care. Utilizing AIDET and the promise to explain the experience the patient can expect, and communicate how the patient will receive excellent and timely care.
General: Teamwork and Service Expectations
1. Display and encourage sensitivity to the needs of patients, visitors, and co-workers.
2. Treat others with consideration, courtesy, and respect.
3. Perform duties willingly and with initiative; shares necessary information so co-workers can do the same.
4. Remain composed and take actions to restore calm in stressful situations.
5. Demonstrate judgment and tact when dealing with others.
6. Cooperate with other hospital departments and work groups.
7. Communicate effectively with patients, visitors, and co-workers; take action to clarify information received from others.
Role Specific: Work role responsibilities
1. Responsible for providing consultation and education related to clinical quality and patient safety, accreditation, regulatory and licensing , risk management, and infection prevention and control; contributing to the evaluation, design, and development of evidence-based guidelines, principles, and/or programs related to area of work as well as facilitating implementation efforts to reduce variation in clinical practice and optimize patient outcomes; assisting with the collection, analysis, report development, and presentation of clinical data for a variety of users including for state, federal, and local agencies; helping to provide education regarding the interpretation of compliance methods when preparing for regulatory reviews, the interpretation of regulatory requirements, and regional project goals; monitoring, reporting, and developing mitigation plans for all occurrences which may lead to liability for SLHD; and supporting SLHD’s continuous survey readiness program to maintain compliance with regulatory standards.
2. Listens to, seeks, and addresses performance feedback; proactively provides actionable feedback to leaders verbally and in writing.
3. Under the direction and sponsorship of the COO, adopts new responsibilities related to the position.
4. Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; champions change and helps others adapt to new tasks and processes. Facilitates team collaboration to support the strategic priorities of SLHD.
5. Develops and utilizes quality improvement performance metrics by to establish improvement success; collaborates with multiple stakeholders, often with competing/conflicting objectives, to ensure development of cohesive and reachable metrics are practical and approved; and facilitates the collection of metric data from workflows and projects by utilizing sound methodology.
6. Facilitates the development of quality improvement initiatives by: implementing methods and tools to develop stakeholders capabilities for process improvements; integrating the use of data-driven improvement principles, tools, and problem-solving methods, and techniques using quality improvement metrics; and developing and updating milestones, detailed workplans, and documentation practices in order to create a clear, logical, and realistic plan.
7. Facilitates quality improvement and Risk Management efforts by: identifying areas of required improvement through utilization review, clinical records audits, patient satisfaction surveys, and auditing surveys; process improvements are compliant with established internal and external regulation requirements at the local, state, and federal levels; conducting root cause analysis, failure mode and effect analysis, and other assessments in response to significant events, near misses, and good catches in order to identify areas of improvement; and exercising sound judgement to escalate high-risk issues and trends to the appropriate SLHD leaders for resolution.
8. Serves as the subject matter expert for quality improvement processes and regulations within assigned departments by: learning current internal policies and external regulations; participating on committees, projects to propose a course of action on the enforcement, development of policies or procedures of regulations and auditing processes; fostering collaborative, results oriented partnerships with SLHD leaders to ensure compliance with regulations and improve patient safety, maintain a safety culture, reporting accuracy, and health outcomes; delivering educational programs to raise awareness for regulation requirement, internal concerns, and system/database usage; and anticipating issues, weighing practical considerations in addressing issues and seeking input and engagement SLHD leaders to work toward resolution.
9. Directly supervises the Patient Experience Coordinator and Employee Health and Infection Control Nurse. Ensures that these functions meet the organization’s needs and goals. Works with the Human Resources Department related to hiring, training, evaluating, disciplining, and termination of personnel they directly supervise.
10. Oversees the organization’s risk management program, assessing, identifying, and advising leaders to resolve the risks that could impede the reputation, safety, security, or financial success of the organization.
11. Engages in consistent reliability testing, conducting planned and random rounding and mock surveys in all areas of the organization to ensure survey readiness.
12. Organizes, compiles, and reports data to identify trends, establish priorities, and recommend improvement activities. Collates and reports quality and other data to oversite federal and state agencies.
13. Works closely with Informatics Nurse and/or other IT Team members for meaningful use and WYFI requirements.
14. Is aligned with physician and provider leadership, attending Medical Staff Meetings and/or other provider meetings as requested.
15. Performs comprehensive, concurrent, and retrospective reviews in a timely manner, using criteria developed and approved by the medical staff and COO.
16. Reviews policy and procedure related to quality and compliance for the organization and each department, making recommendations for improvement and advising the implementation of essential modifications. Ensures that the healthcare services rendered meet or exceed professionally recognized standards of care.
17. Acts as the Executive Sponsor of the SLHD Quality Assurance/Performance Improvement (QAPI) and Safety committees.
18. Provides leadership and extends accountability to leaders through the development, implementation, and monitoring of quality improvement and compliance programs, systems, and initiatives impacting the entire organization. Directs leaders to facilitate performance and process improvements in keeping with patient safety, strategic objectives, and regulatory requirements.
19. Identifies potential quality, compliance, and risk management needs by analyzing data, observing processes, and talking with staff.
20. Provides training to new leaders regarding their specific regulatory responsibilities, oversight agencies, and survey requirements.
21. Cultivates and maintains professional relationships with providers, leaders, and other staff to foster opportunities for improvement in quality metrics, enhanced customer service, and to positively impact core measures.
22. Maintains up-to-date understanding of regulatory compliance objectives and communicates these changes to leadership, providers, and others.
23. Serves as the Privacy/HIPAA Compliance Officer for South Lincoln Hospital District.
24. Performs other duties as assigned.
Desired Knowledge, Skills & Abilities
1. Skills, knowledge, and abilities to enable the successful and effective execution of the role specific work responsibilities for this position (above).
2. Must be able to read, write, and speak the English language.
3. Knowledge of state and federal regulations, policies, and procedures pertaining to the work role responsibilities outlined above.
4. Strong analytical and problem-solving skills
5. Skill in leading others to success, supporting individual and team accomplishments
6. Experience with data visualization tools
7. Proven ability as a self-starter with excellent organization and project management skills with the skill to prioritize work tasks for effective outcomes while executing within tight deadlines
8. Demonstrated ability to collaborate and achieve results via interpersonal and influencing skills while interacting with and adapting to varied audiences
9. Ability to work independently and organize time effectively with proven ability to meet deadlines
10. Ability to comprehend technical medical terminology
11. Ability to manage several priorities at once and to consistently meet required deadlines
12. Ability to foster, maintain, and strengthen professional relationships
13. Ability to perform moderately complex calculations
14. Ability to operate various office equipment
15. Skill in accuracy and attention to detail
16. Ability to perform public relations in a professional manner
17. Ability to maintain confidentiality
18. Ability to read, write legibly and calculate mathematical figures
19. Ability to solve practical problems and deal with a variety of variables
20. Ability to work with others
21. Ability to manage multiple assignments/projects; meet timelines and prioritize responsibility
22. Ability to handle stressful situations and react appropriately
23. Ability to exercise good judgement in appraising situations and making decisions
24. Ability to work and interact effectively and positively with other staff members to build and enhance teamwork across SLHD departments
25. Ability to communicate to complete responsibilities effectively
26. Ability to see to use computer efficiently and read computer reports and correspondence
27. High proficiency with Microsoft office products (excel, word, PowerPoint, etc.)
Equal Employment Opportunity
South Lincoln hospital District will provide equal opportunity employment to all employees and applicants for employment. No person shall be discriminated against in employment because of race, color, gender, age, national origin, ancestry, religion, physical or intellectual disability, marital status, parental status, sexual orientation or any other category protected by law. Employees of SLHD must be free from governmental sanctions involving healthcare and/or financial practices.
Americans with Disabilities Act (ADA) Statement
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit for prolonged periods of time at a desk working on a computer; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee is occasionally required to stand; walk; stoop, kneel, or crouch. The employee must regularly lift and/or move up to 20 pounds. Sufficient vision, hearing, and speech to perform duties is required. Requires the utilization of personal protective equipment to protect against possible exposure to blood and/or body fluids, infection disease, and/or hazardous waste. The employee must be able to read, write, and understand the English language.
Additional Information
Position Type : Full Time
Shift : Day
Contact Information
Stephanie Raver - HR Business Partner
HR
711 Onyx
Kemmerer, WY 83101
Email: sraver@southlincolnmedical.com
Phone: 13078008683 |
