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Deerfield

    Head of Quality - Deerfield, IL, United States - SCA Health

    SCA Health
    SCA Health Deerfield, IL, United States

    3 weeks ago

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    Description
    Quality Standards Coordinator - Hungtingdon Valley Surgery Center

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    • Nursing
    • Full-time
    • Today, SCA Health has grown to 11,000 teammates who care for 1 million patients each year and support physician specialists holistically in many aspects of patient care.
    Together, our teammates create value in specialty care by aligning physicians, health plans and health systems around a common goal:

    delivering on the quadruple aim of high-quality outcomes and a better experience for patients and providers, all at a lower total cost of care.

    We connect patients to physicians in new and differentiated ways as part of Optum and with our new Specialty Management Solutions business.


    • We lead the industry in value-based payment solutions through our Global 1 bundled payment convener, that provides easy predictable billing to patients.
    • We help physicians address everything beyond surgical procedures, including anesthesia and ancillary service lines.
    We are actively recruiting for a Quality Standards Coordinator. This position will manage the following responsibilities.
    Accreditation and regulatory standards

    • Quality improvement processes
    • SCA Quality Standards Manual
    • SCA Governing Body (GB) and Medical Executive Committee (MEC) Bylaws
    • Center Medical Staff Rules & Regulations
    • SCA policies and procedures
    • SCA Medical Staff Services and Credentialing guidelines
    • SCA Medical Staff Services and Credentialing Manual
    • Center and regional education, orientation, and training programs
    • Clinical Resources, Quality Standards, Environment of Care, Credentialing
    Lead, facilitate, and advise the Center Quality Council and internal performance improvement teams:

    • Ensure reporting of all mandatory and center specific monthly and quarterly reports for trends/areas for improvement to the Quality Council and Medical Executive Committee/Governing Body a minimum of quarterly:
    • Medical Record Audit reports; Monthly or quarterly data collection from ongoing systematic chart review to assess quality of documentation.
    • Hospital Transfer/Complication reports
    * measurement of key measures of patient safety and hazard analysis/process redesign (adverse events, root cause analysis).

    • Provide for a detailed assessment and evaluation of the Environment of Care (EOC) and the associated conditions, staff education and readiness and the various processes. Framework for the EOC includes the management processes and systems that affect safety, security, hazardous materials, emergency preparedness, life safety, medical equipment, and utilities management.
    • Risk Management (incident reporting)
    • Service Satisfaction reports (patients, staff and physicians)
    • Center specific quality indicator reports as appropriate
    • Collection, analysis and summary of performance improvement data.
    Root cause analysis.

    • Identification and data collection of center specific quality indicators based on high risk, problem prone procedures as appropriate.
    • Review and revision of the PI Plan on an annual basis and preparation of the annual report of the PI program to the Medical Executive Committee/Governing Body.
    • Documentation of all Performance Improvement activities and maintenance of records for a minimum of three years.

    Coordination of the center policies/procedures and processes to be in compliance with the current standards of applicable regulatory and accrediting agencies, and mandatory SCA Corporate policies.


    • Working with the Administrator/designee to ensure currency of all physician files, medical staff appointments and/or privileges and compliance with credentialing policies and procedures. Coordinating as appropriate the peer review process and aggregate individual peer review data for presentation and review by the Medical Executive Committee and Governing Body at reappointment.
    • Working with the Administrator/designee to ensure currency and completeness of all human resource and education files for center employees and contract personnel.
    Maintain Center Survey readiness

    • Assess center compliance with accreditation standards and regulations in collaboration with leadership and staff.
    • Proactively educate and train the leadership and staff regarding regulatory issues, new statutes/guidelines, and safety/quality/performance improvement activities and their respective responsibilities in carrying out the performance improvement program.
    • Maintain effective communication on current center activities related to Safety/Quality/PI and Accreditation and seek consultation as needed for support from the Regional Quality Coordinator or assigned Group Director.
    Have prior work experience in healthcare.

    • Possess knowledge of standards, survey methodology and related tools and resources for regulatory and accreditation requirements.
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