Job Posting
Director of Quality and Compliance - Main Campus and all locations of SLHD
The Director of Quality and Compliance is a Senior Leader for South Lincoln Hospital District. This position is responsible to support the Quality and Compliance programs for South Lincoln Hospital District. Serving as a subject matter expert, this position establishes, maintains, and strengthens organization-wide Quality and Compliance structure and reporting. This position consults with and advises each department leader in their responsibility to fully own Quality and Compliance efforts for the areas, departments, teams, and functions they lead. This role will advise each leader to be perpetually “survey ready” and may provide support and training to teams, as requested by the leader, to maintain this readiness. The successful candidate for this position will provide recommendations to Senior Leaders regarding holding their leaders accountable for Quality and Compliance challenges. Though not individually responsible to accomplish the day-to-day functions in each department related to quality and compliance, this position acts as the “golden thread” unifying the entire organization in these endeavors and works to ensure that turnover in leadership positions does not negatively affect the quality and compliance of the affected department(s). This position acts as a liaison between the SLHD and the Quality Sub-Committee of the Board of Trustees. The Director of Quality and Compliance supervises all personnel in the Quality department which includes the following SLHD Leaders of Functions: 1) Patient Experience, Safety, and Marketing Coordinator; and 2) Employee Heath and Infection Control.
Education, Certifications and/or Experience
Required:
• 2+ years of documented healthcare leadership experience including quality and compliance initiatives
• Documented professional success in decision making, change management, performance improvement, quality, patient safety, and data analysis in a healthcare setting
Preferred:
• Registered Nurse (RN) with a current license in the state of Wyoming or the ability to obtain such within sixty days of the beginning of employment.
• Bachelor’s Degree in Nursing, Risk Management, Finance, Business Management, or other-related field
• 5+ years of experience leading quality and compliance initiatives in a healthcare setting.
• 2+ years of experience in a Senior Leader or C-suite executive role in a healthcare setting.
• Broad clinical experience in acute, emergency, nursing home, and clinic healthcare settings
Desired
• Master’s Degree in Nursing, Risk Management, Finance, Business Management, or other-related field
• Formal training or certification in continuous process improvement, Lean, and/or Six Sigma
• 5+ years of experience in a Senior Leader or C-suite executive role in a healthcare setting.
• 10+ years of experience leading quality and compliance initiatives in a healthcare setting.
Responsibilities / Functional Job Description
General: Performance Expectations
1. Responsible - works independently, in a safe and appropriate manner. Demonstrates both problem-solving and problem-prevention skills.
2. Sensitive - displays sensitivity to the needs of patients and co-workers. Demonstrates good communications skills and empathy.
3. Timely - recognizes time as a customer's most valuable resource and responds promptly to patients' and co-workers' needs.
4. Accurate - works carefully and precisely, with attention to detail.
5. Coordinated - organizes and delivers service in the proper order. Displays good organization skills and utilizes resources wisely.
6. Thorough - meets all the requirements of his/her position. Is able to evaluate and follow up on his/her services.
General: Standards of Behavior
1. Demonstrates a commitment to living the SLHD standards of behavior through exemplifying in action, a commitment to the values of SLHD, namely:
2. Innovation – continually seeking the latest advances in cost effective healthcare and customer service.
3. Compassion – concern for the individual, empathy for the situation, action to provide service
4. Integrity – doing the right thing; always.
5. Community – supporting, giving and acting to improve where we live, serve, and work.
6. Passion for Healthcare – fervently, avidly, and zealously seeking the improvement of human health
7. Displays this commitment to the standards of behavior through actions and words, by demonstrating the following behavior traits:
8. Adaptability – Responding resourcefully to changes in direction, priorities, schedules, approaches and responsibilities for the good of everyone. Maintaining a positive attitude when faced with a difficult or challenging situation and providing an uplifting and realistic outlook on the opportunities the future may present.
9. Communication – Listening attentively and seeking clarification, being friendly in words and actions, responding to others in a timely manner to ensure satisfaction, comfort and quality care. Utilizing AIDET and the promise to explain the experience the patient can expect, and communicate how the patient will receive excellent and timely care.
General: Teamwork and Service Expectations
1. Display and encourage sensitivity to the needs of patients, visitors, and co-workers.
2. Treat others with consideration, courtesy, and respect.
3. Perform duties willingly and with initiative; shares necessary information so co-workers can do the same.
4. Remain composed and take actions to restore calm in stressful situations.
5. Demonstrate judgment and tact when dealing with others.
6. Cooperate with other hospital departments and work groups.
7. Communicate effectively with patients, visitors, and co-workers; take action to clarify information received from others.
Role Specific: Work role responsibilities
1. Responsible for providing consultation and education related to quality and compliance.
2. Assists with Administration On-Cal (AOD) coverage as assigned and directed by the CEO.
3. Supports leaders in their responsibilities for Quality and Compliance by contributing to their evaluation, design, and development of evidence-based guidelines, principles, and/or programs related to their area of work. Also supports leaders in their responsibility to facilitate implementation efforts to reduce variation in clinical practice and optimize patient outcomes.
4. Acts as a liaison between SLHD and the Quality Sub-committee of the Board of Trustees. Attends board meetings and presents quality data to the Board of Trustees as requested/directed by the CEO.
5. Works to provide interpretative guidance related to compliance methods and regulatory requirements when preparing for regulatory reviews
6. Supports SLHD’s continuous survey readiness program for each leader to maintain compliance with regulatory standards for the area/department they lead.
7. Utilizing Lean and Six Sigma philosophy and principles, provides recommendations and training to leadership related to operational efficiency.
8. Provides support to leaders during their survey/review processes and assists leaders in the creation of plans of correction (POC) as needed.
9. Listens to, seeks, and addresses performance feedback for those they lead.
10. Proactively provides actionable feedback related to Quality and Compliance to leaders verbally and in writing.
11. Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; champions change and helps others adapt to new tasks and processes. Facilitates team collaboration to support the Quality and Compliance requirements of SLHD.
12. Assists leaders to develop and utilize quality improvement performance metrics to establish improvement success, ensure that the development of cohesive and reachable metrics are practical and achievable, collect metric data from workflows and projects by utilizing sound methodology.
13. Facilitates the development of quality improvement initiatives by supporting leaders as they implement methods and tools to develop stakeholders’ capabilities for process improvements; integrate the use of data-driven improvement principles, tools, and problem-solving methods, and techniques using quality improvement metrics; and develop and update milestones, detailed workplans, and documentation practices in order to create a clear, logical, and realistic plan.
14. Facilitates quality improvement efforts by: identifying areas of required improvement through patient satisfaction surveys, and auditing surveys; supporting leaders in their process improvement responsibilities and assists them to ensure these efforts are compliant with established internal and external regulation requirements at the local, state, and federal levels;
15. Leads root cause analysis and other assessments in response to significant and sentinel events in order to identify areas of improvement;
16. Exercises sound judgement to escalate high-risk issues and trends to the appropriate SLHD leaders for resolution.
17. Serves as the subject matter expert for SLHD Quality and Compliance processes.
18. Participates on SLHD committees, serving as the Committee Chair for the SLHD Quality Assurance/Performance Improvement (QAPI) Committee and as the Executive Sponsor of the Safety and Infection Prevention Committees.
19. Fosters collaborative, results oriented partnerships with SLHD leaders to support them to ensure compliance with regulations and improve patient safety, maintain a safety culture, reporting accuracy, and health outcomes.
20. Anticipates organization-wide issues related to Quality and Compliance, weighing practical considerations in addressing issues and seeking input and engagement SLHD leaders to work toward anticipatory resolution.
21. Directly supervises the Patient Experience/Safety/Marketing Coordinator and Employee Health and Infection Control Nurse. Ensures that these functions meet the organization’s needs and goals. Works with the Human Resources Department related to hiring, training, evaluating, disciplining, and termination of personnel they directly supervise.
22. As assigned by the CEO and in coordination with operational leaders, assists with the reporting of data to oversight and credentialing entities and organizations.
23. Engages in consistent reliability testing in coordination with and with the sponsorship of the area/departmental leader, conducting planned and random rounding and mock surveys in all areas of the organization to ensure survey readiness.
24. Organizes, compiles, and reports data to identify trends, establish priorities, and recommend improvement activities. As assigned by the CEO, collates and reports quality and other data to oversite federal and state agencies.
25. Works closely with Informatics Nurse and/or other IT Team members for meaningful use and other quality reporting requirements.
26. Strives for alignment with physician and provider leadership, attending Medical Staff Meetings and/or other provider meetings as requested.
27. Coordinates the performance of comprehensive, concurrent, and retrospective reviews in a timely manner, using criteria developed and approved by the medical staff and CEO.
28. Provides support to leaders as they review policy and procedure related to Quality and Compliance for the organization and each department. Performs policy review audits to ensure timely review and approval. Serves on and leads a Policy Committee as assigned by the CEO.
29. Provides support to leaders as they ensure that the healthcare services rendered meet or exceed professionally recognized standards of care.
30. Makes recommendations to leaders in their facilitation of performance and process improvements in keeping with patient safety, strategic objectives, and regulatory requirements.
31. Identifies potential Quality and Compliance, needs by analyzing data, observing processes, and talking with staff.
32. Provides training to new leaders regarding the importance of researching and understanding their specific regulatory responsibilities, oversight agencies, and survey requirements.
33. Cultivates and maintains professional relationships with providers, leaders, and other staff to foster opportunities for improvement in quality metrics, enhanced customer service, and to positively impact core measures.
34. Strives to maintain an up-to-date understanding of regulatory compliance objectives and communicate these changes to leadership, providers, and others.
35. Serves as the Privacy/HIPAA Compliance Officer for South Lincoln Hospital District.
36. Performs other duties as assigned.
Desired Knowledge, Skills & Abilities
1. Skills, knowledge, and abilities to enable the successful and effective execution of the role specific work responsibilities for this position (above).
2. Must be able to read, write, and speak the English language.
3. Knowledge of state and federal regulations, policies, and procedures pertaining to the work role responsibilities outlined above.
4. Strong analytical and problem-solving skills
5. Skill in leading others to success, supporting individual and team accomplishments
6. Experience with data visualization tools
7. Proven ability as a self-starter with excellent organization and project management skills with the skill to prioritize work tasks for effective outcomes while executing within tight deadlines
8. Demonstrated ability to collaborate and achieve results via interpersonal and influencing skills while interacting with and adapting to varied audiences
9. Ability to work independently and organize time effectively with proven ability to meet deadlines
10. Ability to comprehend technical medical terminology
11. Ability to manage several priorities at once and to consistently meet required deadlines
12. Ability to foster, maintain, and strengthen professional relationships
13. Ability to perform moderately complex calculations
14. Ability to operate various office equipment
15. Skill in accuracy and attention to detail
16. Ability to perform public relations in a professional manner
17. Ability to maintain confidentiality
18. Ability to read, write legibly and calculate mathematical figures
19. Ability to solve practical problems and deal with a variety of variables
20. Ability to work with others
21. Ability to manage multiple assignments/projects; meet timelines and prioritize responsibility
22. Ability to handle stressful situations and react appropriately
23. Ability to exercise good judgement in appraising situations and making decisions
24. Ability to work and interact effectively and positively with other staff members to build and enhance teamwork across SLHD departments
25. Ability to communicate to complete responsibilities effectively
26. Ability to see to use computer efficiently and read computer reports and correspondence
27. High proficiency with Microsoft office products (excel, word, PowerPoint, etc.)
Equal Employment Opportunity
South Lincoln hospital District will provide equal opportunity employment to all employees and applicants for employment. No person shall be discriminated against in employment because of race, color, gender, age, national origin, ancestry, religion, physical or intellectual disability, marital status, parental status, sexual orientation or any other category protected by law. Employees of SLHD must be free from governmental sanctions involving healthcare and/or financial practices.
Americans with Disabilities Act (ADA) Statement
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit for prolonged periods of time at a desk working on a computer; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee is occasionally required to stand; walk; stoop, kneel, or crouch. The employee must regularly lift and/or move up to 20 pounds. Sufficient vision, hearing, and speech to perform duties is required. Requires the utilization of personal protective equipment to protect against possible exposure to blood and/or body fluids, infection disease, and/or hazardous waste.
Additional Information
Position Type : Part Time
Shift : Day
Contact Information
Stephanie Raver - HR Business Partner
HR
711 Onyx
Kemmerer, WY 83101
Email: sraver@southlincolnmedical.com
Phone: 13078008683 |
