Description Oversees quality initiatives and regulatory compliance in the hospital licensed clinics, including providing direction on quality and safety, developing and revising policies in response to regulatory changes, patient safety and quality concerns, patient care needs and evidence-based national guidelines. Establishes systems to proactively identify compliance issues and implements survey readiness activities, tools and educational programs.
Responsibilities
Leads quality and performance improvement efforts for assigned outpatient and/or inpatient and licensed and/or unlicensed clinical areas. Leads large cross-functional process improvement teams to meet performance improvement and quality strategic goals.
Expertly applies performance improvement tools and methodologies to systematically drive, implement and sustain changes in collaboration with administrative, clinical, physician and executive champions.
Identifies and establishes systems for measuring clinical quality, performance, outcomes and opportunity. Analyzes data, prepares dashboards and reports, and presents findings. Recommends actions, as needed. Implements key metrics to measure process, performance, and opportunities.
Ensures compliance with local, state, federal and external specialty certification regulatory standards (such as Commission on Cancer, American Diabetes Association) as the accreditation expert and survey readiness leader.
Acts as lead for survey readiness for all hospital licensed clinics, providing guidance to clinic management and executive leadership for local, state, federal and Joint Commission (TJC)/other licensing agency regulations. Serves as the ambulatory point of contact for survey activities with external regulatory agencies.
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