Littleton Adventist Hospital is a 231-bed, full-service medical center delivering quality care and Level II emergency care for more than 25 years. Located in the Denver suburb of Littleton, CO, the hospital is surrounded by residential neighborhoods, retail, dining, Littleton's charming "old town" area, and abundant outdoor space with trails, nature centers and golf courses. In addition to numerous awards for care excellence, we are also leading the way in health care environmental sustainability. Our associates are actively engaged in protecting the health of our environment, working tirelessly to minimize the negative environmental impacts from our operations. Our sustainable achievements have been recognized with several local and national awards, including the Top 25 Environmental Excellence Award from Practice Greenhealth for three consecutive years (2014- 2016). If you want to be part of a team where our mission to care touches more than just the patient, we look forward to meeting you. For details about Littleton's culture, service and support for healthy environments and one another, visit http://www.mylittletonhospital.org.
Job Description/Job Posting ID: 84502
Clinic/Department: 8673 LAH QUALITY MANAGEMENT
Hospital: LITTLETON ADVENTIST HOSPITAL
Responsibilities for preparation and coordination across the continuum for quality outcomes, safety, and regulatory compliance. Works as a part of the multidisciplinary quality structure reporting to the Chief Nursing Officer. Works collaboratively with the Director of Operational
Excellence to improve quality processes.
Bachelor’s degree in medical field (nursing, medical technology, health information management). Advanced degree and CPHQ preferred.
WORK EXPERIENCE REQUIREMENTS
Four years experience in management in healthcare environment with three (3) years in quality management. Excellent communication, problem-solving, statistical and analytical abilities.
Strong PC skills and knowledge. Strong presentation and delivery skills.
Previous experience with: leading process/performance improvement initiatives; JCAHO preparation, coordination, education and surveys for hospitals; Patient Safety.
Knowledge of Patient Service and Complaint Resolution. Previous management experience.
Ability to collaborate in a matrix structure.
Certified in Nursing Administration or Quality preferred
POSITION DUTIES (ESSENTIAL FUNCTIONS, INCLUDE % OF TIME)
QUALITY - 40%
Participates in facility and system-wide quality initiatives and programs as needed.
Develops and maintains good working relationships with Centura Health management, Porter Nursing directors, chief nursing officer and medical staff leaders.
Uses various communication techniques on a regular basis, to exchange all information necessary and applicable in order to efficiently and effectively fulfill duties.
Maintains expertise in Joint Commission, CMS, CDPHE standards and surveying methods.
Maintains working knowledge of other standard sets such as OIG, OSHA, BME, etc. and maintains excellent working relationship with Centura risk and legal departments.
Provides on-site consultation to individual departments to assure that data is being used in quality improvement and risk management initiatives.
Works collaboratively with Manager of Care Management to achieve Core Measure Excellence and to improve Quality of Patient Care
In concert with clinical data analyst interprets and educates Porter departments with comparative data from Centura, CHI & AHS. Works in concert with clinical data abstractors to oversee data submission for CMS Centura Quality Profile and required Joint Comission external database., as well as Leapfrog, AHRQ and other hospital data submission needs
Serves as resource for quality benchmarks and best practices.
PATIENT SAFETY - 20%
- Oversees Patient Safety for hospital including Patient Safety Committee, State Health Department reports and responses, and Just Culture.
- Oversees improvement initiatives resulting from safety/risk concerns.
- Coordinates safety oversight with other departments: environmental safety, biomedical, plant operations.
STAFF DEVELOPMENT - 20%
- Oversees Patient Representative to Synergize Improvements in quality of care
- Oversee professional review process and coordinate with Medical Staff Office.
- Facilitate departmental involvement with multidisciplinary clinical monitoring groups (e.g., Blood Administration, Medication Administration, Resuscitation Monitoring Group, etc.) and ensure regulatory compliance.
REGULATORY DEVELOPMENT - 10%
Provides expertise in standards. Provides advocacy with regulatory agencies Coordinates Porter educational activities regarding regulatory standards.
Participates in, mock surveys at Centura Facilities
Facilitates annual Joint Commission Periodic Performance Review self-assessment
Coordinates Porter JCAHO regulatory surveys and required responses (normally every 3 years).
PROCESS IMPROVEMENT - 10%
Participate/resource/oversee QI staff support to ongoing process/performance improvement initiatives (e.g., Hand-Off team, SCIP team, etc.)
Assists with Process Improvement as related to Quality Department Programs.
Works collaboratively with the Director of Operational Excellence to promote Process Improvement. Clinical data analyst interprets and educates Porter departments with comparative data from Centura, CHI & AHS.
Oversees Infection Control program expectations.
Important notification to applicants as of Nov. 20, 2014: Effective Jan. 1, 2015, Centura Health will no longer hire tobacco users in Colorado and Kansas. The change to our policy does not apply to associates hired on or before Dec. 31, 2014. Centura Health is an Equal Opportunity Employer, M/F/D/V.