Job ID R2375 Full / Part Time:Full time
The manager is responsible for the leadership direction and management of the hospital-wide Continuous Quality Improvement (CQI) department in collaboration with/under the direction of the CNO. This position supports/directs the provision of the highest quality of patient care and effective utilization and allocation of resources. The Manager ensures the development, implementation and evaluation of quality and safety related policies, practices, programs and services consistent with the institution’s mission, goals and objectives. The Manager reviews/recommends and implements systems and strategies that will be responsive to the ever evolving needs of the clinical and operational areas within Baystate Noble Hospital (BNH) which shall result high quality, safe clinical performance.
Accountable for the management and implementation of key programs including: oversight of quality management, regulatory compliance, patient safety reporting, patient satisfaction/service excellence, patient relations, mandatory Board of Registration in Medicine Patient Care Assessment Program (BORM PCAP), and multidisciplinary efforts with defined teams to meet hospital and system wide goals, Provides organizational support to the Performance Improvement structure including performance improvement service line teams.
The Manager develops and maintains strong working relationship with clinical leaders, physicians/providers at all levels, health information management, finance, human resource representatives, clinical leaders, and all levels of staff promoting a teamwork approach to problem solving. The manager assures strong customer orientation and serves as a representative to visitors and the community in a manner that positively promotes Baystate Health and Baystate Noble Hospital.
1) Direct and supervise assigned personnel including performance evaluation, scheduling and orientation, and training for assigned department staff. Make effective recommendations on hire, transfer, promotion, wage change, discipline, termination and similar actions. Resolve grievances and personnel problems. Assist in development, implementation and compliance with policies and procedures. Prepares annual departmental operating budget, monitors budget performance through the fiscal year. Controls allocations within budget targets.
2) Plans, directs and manages the Quality department which includes quality management, regulatory compliance program, and responding to all internal and external requests for information, data and reports. Responsible for all requirements for Pay for Performance (P4P) contracts, quality and performance improvement initiatives for regulatory and accreditation agencies, including CMS Value Based Purchasing program, Leapfrog, and Joint Commission Oryx measurement. Keeps senior leaders, department directors/managers, current regarding hospital compliance with all quality initiatives.
3) Manages processes for quality data collection, quality reporting, development of reports for quality assessment and communication to clinical staff, leaders, service line teams and governance. Ensures all required quality measures are collected, analyzed, studied for improvement, and reported as needed to meet requirements of CMS, Joint Commission, external agencies, DPH and third party payers. Tracks patterns and trends to report findings to hospital leadership and medical staff leaders and governance.
Manages quality/process improvement studies to support service line and project teams, including reporting data and preparing/delivering formal presentations. Manages data processes for patient safety, performance improvement, patient relations, lean process improvement, dashboard development and creation of reports for communication to service line teams, clinical leaders, and governance. Tracks patterns and trends to report findings to regional hospital leadership and medical staff leaders. Assures that loops are closed relative to action plans and new processes are sustained. Ensures the documentation of all quality and performance improvement and activities is complete, accurate, easily retrievable and maintains confidentiality. Keeps senior leaders, department managers, administrative council members current regarding hospital compliance with all quality initiatives.
Manages all processes related to rapid cycle improvement (PDSA) support, lean facilitation, root cause analysis, failure mode analysis and other improvement methods and tools. Initiates investigations in collaboration with risk management of serious unexpected events and ensures timely reporting to all internal leaders/teams and external regulatory agencies as required.
4) Serves as BNH lead for the Safety Reporting System, monitors occurrences, supports leaders in review of reports and associated improvement efforts, initiates investigations and follow up of serious unexpected safety reports. Coordinates activities of others involved with investigation of serious events and ensures the timely reporting of incidents to regulatory agencies as required.
5) Manages all aspects of the reporting requirements of the Patient Care Assessment Program for the Board of Registration in Medicine (BORM). Reporting includes quarterly case submission and annual/semi-annual reporting, program documents and letters, other reports and correspondence as requested by the BORM and dissemination of all related information to medical staff leaders and chairs and governance.
6) Manages all aspects of reporting and support for the Hospital Quality Council and Hospital Quality Coordinating Committee, including reports from these committees required by the Baystate Health board quality committee. Coordinates, set agenda, keeps minutes and prepares follow-up and correspondence on behalf of these committees. Responsible for support, coordination and performance improvement facilitation of service line teams. Ensures data, safety reports, investigations and core reports are prepared and available to support the advancement of quality, performance improvement and patient safety for service line teams and hospital departments.
7) Leads the hospital committee for regulatory compliance activities. Accountable for leading all Joint Commission preparation activities including supporting tracer activities, survey application, leading formal survey activities, post survey responses, sentinel event alert program. Lead readiness programs to maintain the hospital’s continuous readiness with regulatory agencies including CMS, Ma Department of Public Health, DMH, and Board of Registration in Medicine.
8) Project Management expertise to lead the implementation of ideas, programs and tools, which reflect improved performance and efficiency, optimized medical management and care reflective of use of evidence-based clinical practice guidelines at the bedside. An understanding of health care data management, utilization management, clinical evaluation science and outcomes measurement will be essential. This individual must possess clinical experience and be highly organized at project management; be able to direct the redesign and refinement of quality improvement and medical management projects, support and provide direction to clinical teams in identification of quality and cost reduction opportunities, develop strategies to improve performance in the design and refinement of care delivered across Baystate Noble Hospital.
9) Designs, implements, monitors physician and nursing peer review processes. Develops peer review criteria in collaboration with medical staff leaders which are compliant with the Joint Commission, BORM and departmental requirements. Tracks and monitors patterns and trends. Develops and maintains peer reviews into the reappointments process and ongoing physician performance evaluation (OPPE) and focus performance evaluation (FPPE).
10) Manages the hospital program for patient relations including service excellence team for Baystate Noble Hospital. Oversees processes and programs to respond to patient/family concerns, tracking and trending issues to identify patterns to address to support service excellence at all levels of the organizations. Ensures coordination, investigation, and response to all internal and external patient complaints and/or quality of care concerns brought forth from all sources including patient accounting as required by federal, state and regulatory requirements and within established time frames. Archives all complaints, preparing and supplying semi-annual reports to the Department of Public Health through the Board of Registration in Medicine and others as requested.
11) Collaborates with BH performance improvement colleagues, HIM coding and documentation colleagues to support BNH on committees and projects. Maintains a collaborative working relationship with all staff and external contacts.
12) Serves as resource/liaison/educator to all hospital departments, service line teams, medical staff regarding quality management, and regulatory compliance.
13) Integrity: works with respectful, credible, and professional demeanor. Demonstrates trust-worthy behaviors, i.e. follow through on commitments, maintains confidentiality and appropriate boundaries, displays ethical behavior and decision making
14) Assumes responsibility for own professional growth and development including attending appropriate educational programs and maintaining clinical knowledge relevant to performance improvements responsibilities.
15) Uses appropriate IS systems/web applications to report quality, track quality of care problems and issues, ensuring that communications occur in a highly confidential and timely manner consistent with BH policy.
People Management/Development Experience
Experience in Healthcare Quality
RN License State of MA
Hours/Schedule: Full Time 40 hours Exempt Days
Education:Bachelor of Arts (Required)Languages:Certifications:Registered Nurse - State of MassachusettsWork Experience:Competencies:Responsibilities:Skills:
Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.
Location/Region: Westfield, MA