The person in this position is the organizational owner of the Quality Management System, Quality Data Plan, Quality Improvement Activities and Risk Management Plan. They will be skilled in and help guide others in Accreditation activities and processes and understand Clinical Informatics activities and processes. They will be an integral part of the High Reliability Team
Population Served: N/A
ESSENTIAL FUNCTIONS:
Planning and Prioritizing
Design, develop, implement, and evaluate Quality Management System, Quality Data, Quality Improvement, Risk Management, and Regulatory/Accreditation Compliance programs. Design, develop, implement, evaluate and help lead the High Reliability Team and related activities Organize the Corporate Compliance and HIPAA Programs Design, develop, implement and evaluate a comprehensive data input/output program for unexpected events Design, develop, implement and evaluate organizational quality data reporting, tracking and trending Organize the activities and processes surrounding patient satisfaction, complaints and grievance data Participates and leads in the organizational strategic planning process, including developing objectives, budget preparation, and coordination of activities required for the implementation of strategic initiatives.
Information Gathering
Collect, analyze, and present quality organizational performance data. Perform ongoing risk assessment. Maintain information concerning requirements set forth by the DNV GL Healthcare (DNV), the Department of Health (DOH), Healthcare Financing Administration, the Office of the Inspector General (OIG), Department of Justice (DOJ) and other regulatory agencies.
Decision-Making
Conduct investigation and analysis of adverse events, patient/family complaints, employee concerns regarding healthcare billing practices, and physician/hospital relationships. Facilitate appropriate action from complaints regarding medical staff or allied health professionals.
Communication
Facilitate ongoing communication with the Integrated High Reliability Committee, Reliability Management Team, hospital and medical staff, and the Board of Commissioners. Provide information to hospital and medical staff regarding regulatory agency requirements, standards interpretation, and activities required for compliance. Facilitate communication between departments, staff, leaders, administration, and the Board of Commissioners. Maintain ongoing communication with the professional liability carrier in the areas of risk assessment and prevention, liability exposure, and contract negotiation. Participate in appropriate hospital and medical staff committees. Report ongoing activities relating to regulatory requirements to the appropriate committees.
Technical Proficiency
Demonstrate knowledge and understanding of performance improvement tools and techniques, such as Six Sigmaâ methodologies, PDSA tools, and other proven performance improvement activities. Demonstrate knowledge and understanding of applicable regulatory agency standards and requirements. Demonstrate knowledge of current trends and issues relating to corporate compliance, performance improvement, HIPAA compliance, and risk management.
Teamwork
Coordinate DNV survey preparation activities for the hospital and medical staff. Participate as an executive member of the Reliability Management Team. Facilitate inter and intra departmental performance assessment and improvement activities. Collaborate with all hospital departments in establishing performance standards, performance improvement initiatives, and metrics associated with strategic objectives.
Quality
Conduct an annual assessment of the Quality Management System, Risk Management Program, Corporate Compliance Program, and HIPAA Compliance program, and other programs related to regulatory requirements, including review and revisions. Facilitate the implementation of actions resulting from the analysis of performance improvement activities.
Outcomes
Prepare and present an annual comprehensive report of hospital-wide performance and improvement activities. Facilitate the ongoing improvement of hospital and medical staff functions related to clinical and service performance.
Personal Education
Maintain competency required for the position. Attend education and training programs relating to the performance of required functions.
Work Effectiveness
Facilitate the ongoing improvement of the Quality Management Plan, Corporate Compliance, HIPAA Compliance, and Risk Management Programs in response to identified strategic objective, annual program assessment findings, identified organizational/industry trends, and internal/external customer feedback.
Reliability
Perform job functions with integrity in a dependable and consistent manner.
Education of Others
Design, implement, and evaluate training and education of staff in quality improvement, process analysis, high reliability techniques, group process, and facilitation techniques.
Creating a Safe Work Environment
Identifies safety concerns and actively seeks to resolve these issues.
Stewardship
Assumes the willingness to be accountable for the well-being of the larger organization by operating in service, rather than in control, of those around us.
Ethical Conduct
Consistently communicates and collaborates with colleagues about decisions which involve legal and ethical issues.
NON-ESSENTIAL FUNCTIONS:
Participate in hospital wide committees. Demonstrate proper use of computers, telephones, and voice mail. Record and maintain minutes. Mediate and encourage staff involvement in conflict resolution and problem solving. Performs other non-essential functions as requested.
PHYSICAL DEMANDS:
Sitting: 80%. Standing/Walking: 20%.
Occasional lifting/carrying of supplies and equipment weighing up to 30 pounds.
Occasional pushing/pulling of supplies and equipment weighing up to 20 pounds.
Occasional climbing of stairs to reach other levels of the building.
Occasional stooping/kneeling/crouching to access documents and supplies in lower cabinets.
Frequent reaching/handling/fingering to complete paperwork, use the phone and computer.
Frequent talking/hearing/seeing to interact with staff and vendors.
ENVIRONMENTAL CONDITIONS:
Location: Inside.
Minimal risk of injury due to proximity of moving parts on computer printer, typewriter, and copier.
Minimal exposure to biohazardous materials.
Education/Training: A bachelor’s degree in nursing or equivalent clinical degree required. Will consider non-clinical degree such as MBA or Healthcare Administration.
Experience: Five years of experience in quality and regulatory/accreditation compliance within a healthcare setting is required. CPHQ or CPHRM Certification preferred.
License/Registration: Licensed as a Registered Nurse or equivalent healthcare provider in the State of Washington
We believe Pullman Regional Hospital is extraordinary.
We are a self-sustaining, patient and employee-focused, award-winning hospital with a unique, open, collaborative and inclusive culture.
On a daily basis, more than 500 employees serve patients and communities through Pullman Regional Hospital, the Foundation, and our network of clinics. We are one of the largest employers in Pullman, WA and a community leader in healthcare and philanthropic activities. Together, we continue to raise the bar of expectation for quality healthcare and the patient experience. In this way, the extraordinary for all others becomes the expected at Pullman Regional Hospital.
Our greatest asset is our people. This is our most worthy investment, and it's why we hire passionate people who are aligned in our mission to nurture and facilitate a healthier quality of life for our region.
If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!
