The Regional Senior Director , Quality and Safety position is responsible for the Quality Management Program and the development and analysis of the plans and programs to support continuous quality improvement at Mid Hudson Regional Hospital and Health Alliance. This individual is responsible for defining project scope, developing protocols and instruments, collecting and reporting data, determining necessary process changes, guiding teams and departments to implement changes, and monitoring and documenting outcomes to ensure that quality programs meet or exceed guidelines or requirements, including value based purchasing performance and other pay for performance programs. This position participates in ensuring that the organization is well prepared for all regulatory and accreditation surveys and meets all regulatory agency reporting requirements. Works closely with the VP, Quality & Safety and Clinical & Academic Affairs to choose quality metrics for and ensure compliance with meaningful use requirements. This is a senior level position with responsibility for an organization-wide program to promote the delivery of high quality and fiscally responsible health care.
Directs the day to day operations of the Quality and Safety Management Department in conjunction with other department directors.
Directs, develops, evaluates and continuously improves hospital-wide performance improvement program to ensure program effectiveness through data analysis and education of employees.
Ensures efficiency, effectiveness and accuracy of data collection, analysis and reporting to drive performance improvement processes, and presents data in easy to understand dashboards that clearly display trends so as to assist department and leadership decision-making.
Identifies and coordinates performance improvement activities across all departments and service lines of the organization and coaches department heads in metric choice and development, including dashboard development for ease of tracking performance and outcomes.
Participates in the development of an annual performance improvement plan for the organization in accordance with regulatory agency requirements and the organization's strategic plan.
Participates as a key member in the development of strategies to ensure meaningful use quality metrics are built into the employee health record and that data collection is pristine and reported as required.
Instrumental in ensuring that employee health record development includes required elements to meet regulatory data collection.
Coordinates the development of multidisciplinary performance improvement teams charged with developing strategies with improving quality measures outlined in commercial pay for performance contracts, and serves as facilitator for these groups to ensure successful outcomes.
Supervises and coordinates activities for external database participation and reviews contractual and reporting activities for these databases.
Assesses the organization's compliance with accreditation standards and continued survey readiness, and participates with leadership in Regulatory & Accreditation to coach hospital leadership in survey preparation.
Oversees the medical staff and allied health care professional peer review process, including OPPE and FPPE, as well as the tracking and trending of focused issues.
Develops and implements policies and procedures for assigned areas of the Quality and Safety Department.
Develops, implements and evaluates specified components of the Quality and Safety Department to ensure efficient utilization of resources.
Works with departmental directors in the reporting and screening of incidents and occurrences to determine the next appropriate level of reporting, follow up, documentation, course of action and tracking and trending.
Works in collaboration with subject matter experts and conducts root cause analysis, including formulating questions related to events.
Works with risk management and patient relations through case referral and collaborative case analysis.
Prepares department's operating and capital budget in conjunction with the Vice President and assists with monitoring department's budgets and expense.
Oversees the management of the human resources functions for department staff and ensures appropriate levels of staff recruitment, performance, training and education, competency and professional development.
Collaborates with information systems staff to maintain current systems and plans for existing system upgrades to enhance productivity and efficiency of the operating system.
Promotes and provides quality customer service and proactively identifies and resolves customer issues that relate to quality and performance improvement activities.
Ensures all protocols, policies and procedures are in compliance with the organization's policies and procedures, collective bargaining agreements, CMS and all other applicable accrediting organizations and regulatory bodies.
Does related work as required
. Eight years of administrative or managerial experience, including five years in a hospital or health care agency responsible for quality assurance, discharge planning or clinical case management, three years of which must have been in an acute care setting.
A Bachelor's degree in health, hospital or business administration or nursing required.
Licenses / Certifications:
NYS Registered Nurse Preferred, CPHQ preferred
Comprehensive knowledge of quality assurance functions as they relate to utilization, discharge planning, case management and medical care audits; comprehensive knowledge of the principles of health care administration. Effectively, ability to communicate effectively both orally and in writing; ability to organize, assemble, categorize and prepare data for reporting purposes; ability to plan and supervise the work of others; sound professional judgment; dependability; tact; discretion; integrity; resourcefulness; accuracy; initiative; physical condition commensurate with the requirements of the position
WMCHealth is a 1,900-bed healthcare system headquartered in Valhalla, New York, with ten hospitals on eight campuses spanning 6,200 square miles of the Hudson Valley. WMCHealth employs more than 12,000 people and has nearly 3,000 attending physicians. From Level 1, Level 2 and Pediatric Trauma Centers, the region’s only acute care children’s hospital, an academic medical center, several community hospitals, dozens of specialized institutes and centers, a state of the art Telemedicine program, skilled nursing, assisted living facilities, homecare services and one of the largest mental health systems in New York State, today WMCHealth is the pre-eminent provider of integrated healthcare in the Hudson Valley.