Director Quality - Napa, United States - Providence

Providence
Providence
Verified Company
Napa, United States

3 weeks ago

Mark Lane

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Mark Lane

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Description

Description

THE ROLE


Under the direction of the Executive Director Quality - NorCal, the Director Quality Improvement will be responsible for planning, designing, directing, and executing performance improvement work in alignment with the Value Triple Aim (Quality, Service and Cost Excellence).

The Director will partner with Ministry physician, clinical and operational leaders to develop the infrastructure, reporting mechanisms and strategies to facilitate Performance Improvement and achievement of Providence system, divisional and ministry-specific goals and strategic initiatives.

The Director will ensure the proper preparation and coordination of resources needed to achieve regulatory compliance related to the CMS COP Quality Assessment and Performance Improvement (QAPI) Plan and QAPI Annual Evaluation, and The Joint Commission standards, Co-chaired Quality Committee related to performance improvement, to include the collection, analyses, reporting and on-going monitoring of quality and safety data needed to meet accreditation requirements.

Provides oversight of infection prevention, risk, accreditation, and regulatory activities.


ESSENTIAL FUNCTIONS

  • Plans and manages implementation of all quality related initiatives that reduce risk, improve patient safety and overall quality outcomes for patients being served under the Santa Rosa Memorial Hospital license.
  • Establishes a quality plan and review procedure annually that creates transparency from bedside to board.
  • Establishes a patient safety program consistent with Providence highreliability organization approach that is implemented and consistently sustained by leadership.
  • Routinely reviews risk issues and identifies opportunities to implement change that reduces overall clinical and organizational risk.
  • Assures compliance with regulatory and accreditation standards and integrates multiple requirements into performance improvements plans and initiatives.
  • Aligns and supports team with infection prevention priorities and intervention to assure patient safety overall.
  • Act as an agent on behalf of the best interests of the healthcare consumer; works to address special needs (e.g., disparities in care, health literacy, and patient safety), values and works to provide support and resources as needed.
  • Analytic thinking and knowledgebased decision making: assesses multiple sources of data and information, identifies key interventions that address multiple needs, breaks problems down into parts or steps; (workflow) recognizes multiple layers of cause and effect; collects appropriate information to make decisions informed by available evidenced competencies and patient experiences and perspectives; values and supports transparency and works with a team based environment to sustainably implement change.
  • Development of a knowledgerich environment—supports continuous improvement/learning and transparency using the data available to support decision making (collection, record keeping, access) by using emerging technology and methods.
  • Demonstrates sustainable progress on improvement priorities, and monitors & reports ministry progress to executive leadership, Medical staff, and Governing body.
  • Act as primary resource for SRMH to Clinical Institute/Service Line leaders to provide and/or interpret data for decision making including VOA cost data, clinical outcomes, LOS, payment data from payors, and physician outcomes. Reviews mortalities, and other outcomes as needed and coordinates action plans with ministry leadership (CMO, CNO, department leadership, & NorCal Executive Director of Quality.)
  • In collaboration with regional data analytics, ensures service line clinical institute leaders are knowledgeable and have access to actionable and timely data and oversight internal monthly reporting of key executive clinical institute metrics via quality report.
  • Analyzing, trending, monitoring, and presenting data to core leaders, service line leaders, physicians, etc. and collaborating to drive improvement through developed action plans.
  • Oversees the submission of outcomes data for different payor designations and programs, e.g., Blue Distinction, Anthem, etc.
  • Oversees the submission and validation of quarterly nurse sensitive indicators to NDNQI and other nursing databases. Utilizes the clinical, operational and/or cost outcome reports, trends, and coordinates with the magnet coordinator to communicate progress to nursing leadership. In collaboration with Magnet coordinator routinely identifies appropriate data for Magnet Sources of Evidence.
  • In collaboration with care experience leader evaluates impact of patient experience to CMS, US News, Healthgrades national programs. Provide oversight to development of Performance Improvement plan to improve these national rankings performance.
  • Oversight of data analytics in collaboration with ministry specific leaders for specialty certification designation.
  • Coordinate efforts with SRMH,
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