Position oversees and provides strategic direction, as well as operational support, for Quality Improvement, Risk Management and Patient Safety. Director proactively works to ensure quality and safety by continuous process improvement objectives and measures, advocating for quality, infection prevention, compliance and safety, helping to promote linkage of key services and functions across the organization.
Collaborates with the Medical Staff and Organizational Leadership to create the highest quality measures and insures patient and employee safety
Directs, oversees, plans, coordinates and evaluates a comprehensive program to improve clinical outcomes, enhance value, and minimize patient harm
Provides leadership, clinical oversight and guidance to the company to maintain the highest levels of quality and safety by credentialed providers and their staff.
In the context of this work on quality and safety, brings attention to increasing the efficiency and effectiveness of clinical care delivery. Assures that safe and reliable processes are embedded into the delivery of health care, and develops a culture which values patient safety, clinical excellence, evidence-based medicine, and continuous learning
Monitors emerging clinical and administrative risk issues; develops and ensures communications regarding recommendations to mitigate risk to practitioners and administrators
Oversees the development and implementation of quality programs designed to improve the overall health of the population.
Provides guidance and direction for all levels of physician and clinical staffing with respect to quality improvement and patient centered care programs. Coordinates with facility quality committees to develop a system of quality data collection and reporting with appropriate department administrative personnel.
Serves as a resource and consultant for risk management activities, performance improvement, policy/procedure development and compliance initiatives
Identifies high-risk areas that could cause harm to persons receiving service, visitors and employees.
Oversees regulatory readiness, quality measurement, public reporting, and clinical aspects of pay-for-performance programs and initiatives, holding staff and departments accountable for achieving performance goals
Accountable for full compliance with applicable accrediting, licensing, and state/federal regulatory bodies; Coordinates/participates during internal and external audits and ensures continuous audit preparedness and opportunities for improvement
Ensures compliance program documents are updated with current federal and state regulations
Reviews, manages and forecasts impacts of value-based contracts as well as changes to Medicare/Medicaid emanating from state and federal governing bodies.
Participates in strategy development and implementation to respond to evolving business and industry requirements. Monitors changing marketplace and state/federal regulatory environment for tactical and strategic changes affecting the current and future business
Creates, documents and manages Quality system and business processes to ensure a consistent service delivery model. Implements, educates, and encourages incident reporting throughout the company.
Directs all aspects of the operating budget, strategic planning, quality & patient safety development and recommendations; the delivery and monitoring of clinical quality; and improving patient safety.
Works with IT and Divisional leaders to ensure the collection and reporting of data that is highly accurate and can demonstrate the organization’s standard of quality. Administers and manages Quality Improvement data (scorecard, quarterly reports, ad hoc audits, provider competency measures, review programs). With IT, ensures integrity of data is maintained and the timely capture of relevant information
Participates in the orientation and education of Medical Staff, Chiefs, Service Line Directors and other medical staff members to policies and procedures related to quality and patient centered care.
Supports facility department chiefs in standardizing patient safety procedures, quality measurements and regulatory or accreditation compliance as it relates to quality
Participates in the management and support of professional liability litigation
Administers and manages Risk Management program data; ensure integrity of data is maintained and timely capture of relevant information
Coordinates process improvement projects within quality and assists with facilitation of operational process improvement
Maintains effective communication with hospital leadership and staff, physicians, payers, patients, and other customers who use the services of the department
Coordinates and oversees root cause analyses and failure modes and effects analyses and debriefings
Oversees, in collaboration with clinical staff, the ambulatory surgery infection control program
PRIMARY DUTIES & RESPONSIBILITIES
Provides oversight of Spectrum’s affiliate business, Fides LLC.
Facilitates, develops, and implements special projects as assigned by the CMO
Establishes and ensures appropriate practices relating to risk management file and record retention maintenance
Assesses the needs and expectations of all customers; ensures customers easy access and communication and develops strategies, partnerships and plans to maintain and continuously improve levels of customer service
Collaborates with other executives and engages with leaders and clinicians throughout the organization to build quality, efficiency, effectiveness and a sense of shared accountability
Supports and mentors’ employees of the department and other staff, students, and trainees with interest in quality and patient safety
Maintains required licensure and participates in ongoing personal and professional development maintaining competency and expertise in quality and patient safety
Regularly attends and participates in required meetings, during and after normal business hours
Ensures development of strong positive relationships and collegiality among the practice and organization’s resources and staff
Participates in ongoing personal and professional growth, development and education; maintains any required licensure/certifications
Always demonstrates professionalism and promotes a positive work environment
Displays cooperative behavior and interacts positively and effectively with others to promote a team environment
Performs other duties necessary to maintain the overall efficiency and continuity of the department
Is proactive in identifying, reporting and participating in the resolution of any potential or actual patient safety issues
Continually maintains exposure to national trends in quality improvement methodology
Minimum 5 years of relevant clinical experience in quality, patient safety, regulatory and accreditation, or performance improvement
Bachelor’s degree in healthcare related field, Master’s degree required
Certification with CPHQ, CPHRM, and/or CPPS desired
Knowledgeable and experienced in Lean, Six Sigma, PDSA or other performance improvement methods, with record of successful improvement projects
Strong record of progressive leadership experience including, project management, collaboration
Knowledge of federal, state, and local statures related to healthcare and safety as well as The Joint Commission and AAAHC standards
Proficient analytic and computer skills including use of statistical process control charts, with strong writing, problem solving, and communication skills
Highly organized with ability to prioritize and manage time effectively
Excellent customer service and interpersonal skills
Ability to communicate effectively with excellent verbal, written and presentation skills
High degree of confidentiality and accountability
PHYSICAL DEMANDS / WORK ENVIRONMENT
Daily use of computer operating instruments; stationary PC, Laptop PC, keyboard, mouse and other office equipment
Travel to various sites of service. Flexibility on work hours to coincide with project needs
Attendance at after-hours meetings, as necessary
May be required to sit or stand (presentations/meetings) for extended periods of time
Light lifting of paperwork, folders or other general record keeping materials
Spectrum Healthcare Partners is Maine’s largest multi-specialty, physician-owned and directed professional organization and is comprised of over 200 physicians practicing in the areas of anesthesiology, orthopaedics, pain management, pathology, radiation oncology, radiology, and vascular & interventional services. Spectrum provides services at many of Maine’s hospitals throughout the state and in eastern New Hampshire.
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