Located in the scenic, historic and charming Southwest Colorado town of Durango, Mercy Regional Medical Center (MRMC) is a full-service, acute care hospital with Level III Trauma designation. Recognized by Healthgrades (a leading, independent health care ratings company) with awards for Outstanding Patient Experience and Patient Safety Excellence, as well as an “A” Hospital Safety rating from The LeapFrog Group, Mercy Regional Medical Center blends state-of-the-art technology with a serene and comfortable environment to promote well-being and healing. Specialty services include emergency care, surgical care, cardiac care, an Orthopedic and Spine Center of Excellence and a Family Birthing Center equipped with every amenity and a dedicated surgical suite. Durango residents experience an exceptional quality life with world-class outdoor recreation including snow sports, river sports, hiking, biking and more. Learn more about us at: http://www.mercydurango.org/
Job Description/Job Posting ID: 79413
Clinic/Department: 8673 MRMC QUALITY MANAGEMENT
Hospital: MERCY REGIONAL MEDICAL CENTER
Thinking of moving to Durango? Visit http://www.move2durango.com/ to learn more about the Durango lifestyle.
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 Medical Officer. Works
collaboratively with the Director of Operational Excellence to improve quality processes.
Responsible for providing leadership support for clinical organizational performance improvement, patient safety, risk management, infection control, peer review, regulatory readiness, data analysis and reporting, and patient experience.
Leads a team of 9 individuals in accomplishing the goals of the Quality Resources department of the organization.
Responsible for annual updates of the Quality Assurance and Performance Improvement Plan, and subsequent work product. Teaches principles of High Reliability, Patient Safety, Just Culture, Change Management, and Performance improvement to staff at all levels.
Provides leadership for Quality Operations Committee, and HRO/Patient Safety Committee. Position participates in various committees throughout the organization including: Trauma Committee, Perioperative Service Committee, Management Council, and Clinical Transformation. Provides support and reports for the Quality Committee of the board.
Establishes a comprehensive direction for the patient experience program by defining goals and establishing mechanisms to accomplish the established goals. Provides oversight for patient satisfaction survey delivery and results reporting.
Directs the management and use of patient adverse event/occurrence information; reviews internal event reports and fosters a culture of safety throughout the organization.
Ensures data submission and reporting are complete, accurate and timely both within in and external to the organization.
Minimum Education Requirements
Bachelor's degree in medical field (nursing, medical technology, health information management).
Advanced degree and CPHQ preferred.
Minimum 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.
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
JCAHO, 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 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 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 JCAHO external database, as well as
Leapfrog, AHRQ and other hospital data submission needs.
Serves as resource for quality benchmarks and best
Oversees Patient Safety for hospital including Patient Safety
Committee, 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.
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.
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 JCAHO Periodic
Performance Review self-assessment. Coordinates Porter
JCAHO regulatory surveys and required responses (normally
every 3 years).
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.