STATEMENT OF POLICY
A key focus of Centura's overall business strategy is talent development. Centura is committed to providing the tools and processes that will enable associates to plan their careers. The preferred practice is to post available positions on the Centura Health Career Website allowing visibility to job opportunities at Centura.
Associates are eligible to apply for an open position if they are:
1. Active in their current position for at least six months or have manager and HR approval to be released early;
2. Ratings meet expectations or higher on their PFD review;
3. No written warning or Performance Improvement Plan (PIP) within the last six months unless their manager receives approval from HR; and
4. Continuous sustained improvement is demonstrated.
Centura's general practice is to post available positions on the Career Website for a minimum of three business days (HR reserves the right to close a posting based on the number of applications received within the three business days). The position may be posted internally and externally simultaneously. The organization reserves the right to post internally only before posting externally.
JOB DESCRIPTION/JOB POSTING ID: 86824
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 Group VP of Patient Quality & Patient Experience. Will coordinate group activities and committees within the operating group and participate in system wide committees as the flagship lead of the operating group.
- 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.
- Ability to engage and influence clinicians, telling the story, painting the vivid picture for quality and safety enhancements with strong relationship building skills.
- 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; TJC preparation, coordination, education and surveys for hospitals; Patient Safety.
- Knowledge of Patient Service and Complaint Resolution.
- Previous management experience.
- Ability to collaborate in a highly complex and matrix structure.
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, St. Anthony Hospital 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 TJC, HCFA (CMS), 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 Administrative Director of Nursing to achieve Core Measure Excellence and to improve Quality of Patient Care
- In concert with clinical data analyst interprets and educates St. Anthony Hospital 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 TJC external database., as well as Leapfrog, AHRQ and other hospital data submission needs
- Serves as resource for quality benchmarks and best practices.
- Coordinates Quality Council Team Meetings.
PATIENT SAFETY - 20%
- Oversees Patient Safety for hospital including Patient Safety Council, State Health Department reports and responses, and Just Culture and Red Rule Implementation
- Oversees improvement initiatives resulting from safety/risk concerns.
- Coordinates safety oversight with other departments: environmental safety, biomedical, plant operations.
STAFF DEVELOPMENT - 20%
- 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 St. Anthony Hospital educational activities regarding regulatory standards by facilitating the Hospitals Regulatory Readiness Committee..
- Participates in, mock surveys at Centura Facilities
- Facilitates annual TJC Periodic Performance Review self-assessment
- Coordinates St. Anthony Hospital TJC 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 to promote Process Improvement. Interprets and educates St. Anthony Hospital departments with comparative clinical 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.