Director-Quality and Accreditation - Baptist Memorial Health

Summary

This role will report to the Chief Medical Officer. Provides leadership for Quality and Accreditation programs. Incumbent is responsible for assuring hospital compliance with alllocal, state and federal regulations as well as accrediting organizations. Incumbent is accountable for assigned departments 24 hours per day, 7 days per week.

Responsibilities

Quality:

Entity director for quality measure reporting for value-based purchasing to CMS, for publicly reported quality ratings for CMS, Leapfrog, and other benchmarking organizations using administrative databases, quality-related clinical registries, and payor-sponsored benchmarking programs. Provide oversight to ongoing monitoring and assessment of key quality indicators that are reported to the State, CMS, and The Joint Commission.

Serve as a resource for interpretation of regulatory, accreditation and disease-specific care certification standards. Responsible for hospital specific and national report downloads.

Oversee abstracting for completing data entry, run monthly core measure reports (CMS/TJC) and other requested reports as needed.

Maintain databases and sources of information for quality initiatives, accreditation efforts, and regulatory mandates.

Disseminate reports as needed throughout hospital departments. Provide customized reports as requested by CMO.

Report quality data to hospital departments and committees.

Lead team in evaluating vendor quality data analytics and generate departmental quality data reports for purposes of performance improvement.

Participate in system Quality initiatives as primary representative of entity. Entity lead for physician data and dashboard reporting for performance improvement and OPPE, FPPE.

Work collaboratively with Patient Safety and Performance Improvement in order to foster an environment of learning and high reliability organization.

Actively participate in performance improvement initiatives within the hospital and system.

Collaborate with Risk Management to provide data to support patient safety initiatives, including National Patient Safety Goals.

Collaborate with IP and risk management to develop hospital wide safety plans &programs and ensure a system wide staff education program regarding all safety and emergency management plans.

Collaborate with Director of IP in collecting, reporting infection-related quality data forhospital acquired infections, and disseminating this information to medical staff and healthcare team.

Must have familiarity with RCA and Failure Modes & Effects processes. Must be proficient in Excel, Epic EMR, Cogito software, control charts.

Accreditation:

Responsibility for coordinating disaster drills, including documentation required internally or externally to regulatory or governmental agencies and provides guidance

and feedback to staff regarding those drills.

Must have working knowledge of regulatory and accreditation requirements including TJC and CMS, and quality standards. Responsible for ensuring hospital compliance. Coordinate self-assessment/mock surveys and all regulatory/accreditation site visits according to guidelines/manuals of the various agencies.

Coordinate onsite survey processes with regulatory agencies, both announced and unannounced.

Primary responsibility for communication with regulatory agencies.

Monitor implementation of standards throughout hospital by review of policies and procedures as they are submitted for approval and surveillance rounds for implementation and staff knowledge.

Communicate with administration and departmental leadership any needs relative to implementation or compliance with standards.

Communicate with all accreditation agencies for any direction or questions relative to compliance or implementation as necessary to assure the hospital and clinics maintain survey readiness.

Assure timely communication of regulatory and accreditation standards, standard changes and updates to appropriate staff in a timely manner.

Assist in interpretation of standards to hospital department managers and staff as needed. Coordinate investigations in cited complaints and/or deficiencies and respond to regulatory agencies with required plan of action.

Coordinate the measurement and analysis of data to ensure that improvements in process for regulatory compliance have been sustained over time.

Conducts patient and system tracers in patient care through observation of practice.

Management:

Responsible for all aspects of the management of the department including:

Interviewing, selecting, orienting, evaluating, and terminating staff. Supervises quality coordinators, clinical registry quality data reviewers, and any other positions added as necessary for quality/accreditation activities.

Planning for the professional development of staff

Assisting in development and completion of annual goals

Recommends a sufficient number of qualified and competent persons to provide care/service

Monitors staffing needs and utilization of assigned areas and directs any appropriate alteration

Communicates schedule and/or any alterations to staff

Demonstrates good organizational skills in the preparation of daily work schedules andthe assignment of duties and responsibilities to staff members

Involve associates in decision making.

Requirements, Preferences and Experience

Baccalaureate degree in other healthcare related field.

Master of Informatics/MHA preferred

3 years in Quality, Accreditation, Management

Must have familiarity with RCA and Failure Modes &Effects processes. Must be proficient in Excel, Epic EMR, Cogito software, control charts.

Required: BSN with current Tennessee state RN license Certified Professional in Healthcare Quality upon hire or within 12 months of hire.

About Baptist Memorial Health Care

At Baptist, we owe our success to our colleagues, who have both technical expertise and a compassionate attitude. Every day they carry out Christ's three-fold ministry-healing, preaching and teaching. And, we reward their efforts with compensation and benefits packages that are highly competitive in the Mid-South health care community. For two consecutive years, Baptist has won a Best in Benefits award for offering the best benefit plans compared with their peer groups. Winners are chosen based on plan designs, premiums and the results of a Benefits Benchmarking Survey.

At Baptist, We Offer:

• Competitive salaries
• Paid vacation/time off
• Continuing education opportunities
• Generous retirement plan
• Health insurance, including dental and vision
• Sick leave
• Service awards
• Free parking
• Short-term disability
• Life insurance
• Health care and dependent care spending accounts
• Education assistance/continuing education
• Employee referral program

Job Summary:
Position: 744 - Director-Quality and Accreditation
Facility: BMH - Memphis Hospital
Department: ME Performance Improv & Accr Baptist Memphis
Category: Leadership & Administration
Type: Non Clinical
Work Type: Full Time
Work Schedule: Days
Location: US:TN:Memphis
Located in the Memphis metro area