AVP Clinical Quality, Regulatory Affairs, Quality; Day
Title: AVP Clinical Quality, Regulatory Affairs
Department: Office of Quality Patient Safety
Requisition #: 202626
Shift: Primarily day
Posting Date: 4/8/2020
Location: HealthAlliance-Clinton Hospital, Leominster Campus
HealthAlliance-Clinton Hospital is part of the UMass Memorial Health Care system. Serving northern central Massachusetts, we are committed to improving the health of people through excellence in care and comprehensive health services. Promoting healthy lifestyle habits, we serve as a role model by having a tobacco and smoke free campus and hiring nicotine free employees. By exploring careers with us, you are committed to giving your best to our patients, our community and everyone working on our HealthAlliance-Clinton Hospital Care Team. Whatever your career choice, know that at HealthAlliance-Clinton Hospital you can make a difference.
This position is responsible for the overall operation and administration of Quality, Patient Safety, Hospital Staff Peer Review, Risk Management Programs, Care Coordination, Infection Control, Compliance as well as all Accreditation programs and Regulatory Quality Data Abstraction/Reporting functions.
This position ensures the continual improvement of clinical processes to evaluate and improve the quality of health care evaluation, reporting of clinical quality indicators, risk management, infection control and prevention, compliance, and care coordination. Responsible for the coordination and oversight of activities to achieve external accreditation, as well as associated and specified regulatory processes.
Additionally, this position is responsible for the submission of data under the general topic of Pay for Performance, Core Measures (etc.) and for leading efforts to optimize such performance. The position also functions as the PCAC Coordinator for the organization.
As a member of the Quality, Compliance and Regulatory Affairs Management Team, this position is responsible for contributing to the development and execution of strategies and goals for the division. This position works with System leaders to leverage expertise.
- Develops proactive risk assessment and reduction strategies and programs, as well as responds to the need for development/revision of policies, processes or systems.
- Develops educational and informational programs and materials designed to educate Physicians, Nurses and other staff about Performance Improvement, Regulatory Requirements, National Patient Safety Goals, CMS Conditions of Participation, Core Measures, Value Based Purchasing, The Joint Commission Standards, as well as other metrics/topics as necessary.
- Directs External Accreditation preparation activities as a coordinated, ongoing process. Delegates specific responsibilities and functions to teams, committees, and departments, and assures these areas meet regularly to review standards and achieve and maintain necessary results in all areas. Develops tactics to meet new standards/regulatory reporting needs within the appropriate time frames.
- Participates in the design, communication, implementation and evaluation of the hospital’s quality improvement programs and projects. Coordinates and oversees such efforts throughout the hospital and related entities to ensure compliance.
- Evaluates the Performance Improvement program and Compliance Work Plan at least annually for Board approval.
- Ensures/facilitates continual improvement activities related to regulatory quality metrics/data.
- Participates in strategic planning for the Quality programs.
- Manages personnel and processes related to data abstraction and reporting for CMS, MassHealth and other agencies as required.
- Maintains thorough knowledge of regulatory and accrediting body requirements. Interprets new laws, standards, and regulations in order to direct the development, revision, communication, and implementation of new policies, processes, or systems to ensure ongoing achievement of these external requirements. Works with other directors to understand the interrelationships between achieving external standards and resource utilization and advises senior management on the impact of any tradeoffs which are contemplated.
- Maintains a collaborative, team relationship with all levels of hospital management, employees, and physicians in order to effectively contribute to the group’s achievement of goals and to help foster a positive work environment. Serves as primary contact for patient complaints from intake to resolution and teaching.
- Directs the development, evaluation and modification of a Risk Management program to meet the needs of the system, its employees, and physicians.
- Develops and utilizes performance metrics to continually improve quality and operating efficiency.
- Acts as consultant for Management, the Medical staff and Senior Management Team on issues of quality improvement, patient safety, risk management, care coordination, clinical compliance, and external accreditation and recommends annual quality organizational goals.
- Oversees, coordinates, assists and manages the local work and approves the work-product of the HA-C Director of Compliance and Privacy Officer in coordination with System Corporate Compliance, the HA-C CEO, and the HA-C Board of Trustees.
- Consults with UMMHC System-level experts and overseers within the scope of their duties as needed and prudent, including but not limited to Quality, Safety, Risk, Regulatory Affairs, Compliance, UR/CM, legal and audit.
- Works in conjunction with System Compliance Officer and/or HA Board on all compliance concerns.
- Directs projects such as Pay for Performance to maximize dollars and improve quality.
- Serves as leader for Quarterly Audit and Compliance Meeting, as well as Quality Meetings.
- Coordinates and directs the work of the Manager of Infection Control and Prevention to ensure the organization meets all relevant standards and pursue best practices consistent with UMMHC goals and national patient safety standards.
Standard Management Level Responsibilities:
- Directs and supervises assigned personnel including performance evaluations, scheduling, orientation, and training. Makes recommendations on employee hires, transfers, promotions, salary changes, discipline, terminations, and similar actions. Resolves grievances and other personnel problems within position responsibilities.
- Develops and recommends the budgets for the areas managed. Manages activities to assure financial goals are met.
- Coordinates the assignment of tasks and helps resolve technical and operational problems. Evaluates the impact of solutions to ensure goals are achieved.
- Provides effective direction, guidance, and leadership over the staff for effective teamwork and motivation, and fosters the effective integration of efforts with system-wide initiatives.
- Meets established productivity standards.
- Facilitates and promotes the sharing of knowledge and content throughout departments.
- Takes responsibility for ensuring that all work outcomes satisfy the UMass Memorial Health System True North.
- The individual must support the mission, vision, and goals of HealthAlliance-Clinton Hospital and serve as a role model for CARES values.
- Adheres to change control processes.
- Participates in cross training to optimize department resources.
- Demonstrates excellent attendance and actively participates in a variety of meetings and training sessions as required.
- Demonstrates a friendly, responsive, service-minded attitude to all internal and external customers.
- Communicates ideas effectively. Shares information and keeps others properly informed. Gives, and is open to useful feedback.
- Adheres to the HealthAlliance-Clinton Hospital Code of Conduct and Behavior Standards and dress code.
- Complies with established environment of care/safety policies and procedures and all health and safety requirements.
- Maintains and fosters an organized, clean and safe work environment.
- Contributes to the development and application of process improvements.
- Maintains a collaborative, team relationship with peers and colleagues in order to effectively contribute to the group’s achievement of goals and to help foster a positive work environment.
- Attends staff meetings and in-service programs as required or directed. Keeps current with hospital and unit changes by reading communication boards and/or books, bulletin boards, posted notices and reads and responds to e mails on a regular basis.
- Practices cost containment and fiscal responsibility through the efficient use of supplies, equipment, time, etc.
- Encourages and supports diverse views and approaches, creating an environment of professionalism, respect, tolerance, civility and acceptance toward all employees, patients and visitors.
- Integrates diversity into departmental objectives, such as hiring, promotions, training, vendor selections, etc.
- Participates in performance improvement initiatives and demonstrates the use of quality improvement in daily operations.
- Ensures compliance with regulatory agencies such as Joint Commission, DPH, etc. Develops and maintains procedures necessary to meet regulatory requirements.
- Ensures that department complies with hospital established policies, quality assurance programs, safety, and infection control policies and procedures.
- Ensures adequate equipment and supplies for department.
- Develops and maintains established departmental policies, procedures, and objectives.
- Ensures compliance to all health and safety regulations and requirements.
- Performs similar or related duties as required or directed.
All responsibilities are essential job functions.
- Health care related master’s level degree
- Clinical background preferably as a RN preferred
- CPHQ certification a plus
- 7 years of management or director level experience including quality, risk management, compliance, case management, regulatory affairs, and external accreditation process within MA acute care hospitals.
- 5 years conducting complex compliance (or related) investigations.
- Familiarity with state, federal and accrediting body regulations in healthcare.
- Possesses and applies the skills and knowledge necessary to provide care to patients and customers throughout the life span, with consideration of aging processes, human development stages and cultural patterns in each step of the care process.
- Knowledge of peer review standards, quality of care and performance improvement processes.
- Knowledge of current clinical standards of practice.
- Ability to implement an improvement plan, supervise and educate others during implementation, and to assess the plan’s effectiveness.
- Ability to influence change without direct authority.
- Ability to prepare and present to large and small audiences, and to effectively facilitate meetings.
- Excellent interpersonal, communication, and organizational skills.
- Ability to work independently and as a team member.
- Ability to manage multiple priorities and deadlines.
- Ability to communicate clearly, accurately, and succinctly verbally and in writing.
- Excellent analytical skills.
- Proficient with computer programs and applications (Word, Excel, Outlook, Internet Explorer).
- Ability to read, write and speak clearly in English.
- Possesses and applies the skills and knowledge necessary to provide care to patients and customers throughout the life span, with consideration of aging processes, human
Unless certification, licensure or registration is required, an equivalent combination of education and experience which provides proficiency in the areas of responsibility listed in this description may be substituted for the above requirements.
Department-specific competencies and their measurements will be developed and maintained in the individual departments. The competencies will be maintained and attached to the departmental job description. Responsible managers will review competencies with position incumbents
Standards of Respect:
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