Quality Assurance and Accreditation Manager

Smithfield, Virginia Hiring Range $91,000.00 - $125,125.00/Annual Actual pay is determined based on job-related factors such as relevant experience, education, credentials, skills, internal equity, and business needs. Overview The Quality Manager serves as a highly visible, energetic leader and champion for quality throughout the organization, and is responsible for implementation of the quality program. The Manager promotes high reliability for recommended evidence-based care for every patient, everywhere, every time assuring a focus on people, process and technology to improve performance.

The Manager assures accurate and timely submission of all required data and information for required and voluntary quality reporting programs. The Manager supports a continuous learning environment and adheres to just culture principles. The Manager assures ongoing and up to date knowledge of required quality reporting programs and specific quality measures within each of the reporting programs.

Knows where to obtain information on measure specifications. The Manager assures high reliability for recommended evidence-based care for every patient, everywhere, every time assuring a focus on people, process and technology to improve performance. The Manager assures appropriate and up to date content for facility education, training and communication related to quality management and assures alignment and coordination of quality recognition programs with the facility wide quality program.

For example, Stroke Certification, Accreditation for Cardiovascular Excellence, Baby Friendly Designation, etc. The Manager is responsible for the role of facility Stroke Coordinator and assures coordination/management of the stroke patients as well as the organizing, planning, directing, and evaluating of services provided. The Manager provides leadership, direction and mentorship/support to the staffing needs for stroke patient care.

The Manager will act as a resource within RHS in providing best practice and evidence-based stroke care to this patient population. The Manager assures accurate and timely submission of data and information for required and voluntary quality programs and assures data meets validation requirements for the facility. The Manager has deep knowledge of quality data applications and serves as a content expert on navigation and use (such as Premier).

The Manager applies the principles of performance and process improvement to quality improvement projects. The Manager designs and conducts quality improvement training for the facility. The Manager works closely and collaboratively with medical, nursing and clinical leadership to implement improvement strategies to continually improve quality and safety; and contributes to establishing the annual quality and safety plan and contributes to the year-end summary report of progress toward goals and related achievements.

• Oversees facility quality management and quality assurance program, assures structure supports required reporting for quality and pay for performance programs. Assures ongoing and up to date knowledge of required quality reporting programs and specific quality measures within each of the reporting programs. Knows where to obtain information on measure specifications. Assures high reliability for recommended evidence-based care for every patient, everywhere, every time assuring a focus on people, process and technology to improve performance. Assures appropriate and up to date content for facility education, training and communication related to quality management. Assures alignment and coordination of quality recognition programs with the facility wide quality program. For example, Stroke Certification, Accreditation for Cardiovascular Excellence, Baby Friendly Designation, etc. Assures accurate and timely submission of data and information for required and voluntary quality programs, including but not limited to: CMS IQR and OQR: Measures and submission of data, CMS VBP, HAC Reduction and Readmission Reduction Programs, VA Medicare (DMAS) Quality Program, Commercial Payer Quality Program (Anthem Q-HIP) and Leapfrog Hospital Survey. Assures data meets validation requirements for the facility. If the facility is selected for external validation, assures accurate and timely submission of validation records, data and information. Oversees quality data management, assures data is accurate, timely and displayed in meaningful way to end users. Has deep knowledge of quality data applications and serves as content expert on navigation and use (such as Premier). Oversees quality data analysis, assures appropriate data visualization tools and methods are utilized, such as basic statistical techniques to present data (e.g., mean, standard deviation) and use of statistical process control chart (e.g., common and special cause variation, random variation, trend analysis) Interprets data to support decision making (e.g., benchmarking, outcome data). Identifies improvement opportunities based on analysis of facility data, emerging national, state and local quality of care trends and issues. Selects appropriate quality, performance and process improvement methods and tools. Facilitates the use of process analysis tools to display data (e.g., fishbone, Pareto chart, run chart, scatter gram, control chart). Provides oversight of quality related improvement projects and efforts, assuring alignment and coordination throughout the facility. Facilitate establishment of priorities for performance/ quality improvement activities and development of performance/quality improvement action plans and projects Facilitate program development, evaluation, planning, projects, and activities Facilitate development or selection of process and outcome measures. Facilitate evaluation/selection of evidence-based practice guidelines (e.g., for standing orders or as guidelines for physician ordering practice). Facilitate or participate in the development of clinical/critical pathways or guidelines. Aid in evaluating the readiness for participation in quality programs, data bases, certifications and specialty accreditations and awards. Implements the facility accreditation program, providing leadership to ensure compliance with accreditation and regulatory requirements at the national, state and local levels, and develops and maintains procedures necessary to meet regulatory requirements and achieve sustainable, organization-wide readiness. Knowledge of accreditation standards, CMS Conditions of Participation (COPs), OSHA standards, ISO 9001 standards including document control and internal audits, NFPA, ANSI ST79 and VDEQ standards. Manages accreditation cycle process and CMS survey and certification process and accreditation survey application management oversight. Manages CMS complaint surveys and CMS validation surveys in collaboration with the facility Quality director. Maintains knowledge of standard level findings, condition level findings and immediate jeopardy designation findings, assures appropriate corrective action plans and monitoring for all levels of findings. Manages DNV GL accreditation and ISO certification surveys in collaboration with facility Quality director. Coordinates on-site survey process and coordination with facility Quality director. Assures organization wide survey readiness with ongoing assessments of compliance, coordinates mock surveys and follow up of corrective action plans and monitoring. Design organizational performance/quality improvement/accreditation management training. Provide training on performance/quality improvement/ accreditation management, program development, and evaluation concepts. Evaluate effectiveness of performance/quality improvement/accreditation management training. Develop/provide survey readiness training (e.g., accreditation, licensure, or equivalent). Coordinates the development and the implementation of the 10 performance standards for stroke and ensures compliance with standards of regulatory/ facility/nursing (if applicable) practice, standards of care and job performance standards which promote optimal care delivery. Meets and Maintains accreditation and regulatory standards. Participates with the members of RMG/RHS leadership, governing boards, councils, and executive teams in order to assist or provide input and direction in the development of Stroke Strategic initiatives, Goals and Objectives and Evaluation/Integration of Care and Services into and with related RHS Services. Leads the development, maintenance and systemization of policies, procedures, care and services provided to the stroke patients. Effectively coordinates and integrates services throughout RHS and the community in order to provide a continuum of care for our patients. Facilitates in Quality & Risk Management initiatives to develop and measure the effectiveness of patient safety interventions and outcomes. Engages physicians into the governance and administration of the Stroke Strategic and Operational Goals and Objectives. Ensures integration of physicians and administration, creating a partnership that achieves service excellence and economic growth. Demonstrates the ability to address physician issues/concerns and follow-through within 72 hours. Participates in the planning and monitoring of the budget for defined areas to include appropriate stroke resource allocation determination. Demonstrates accountability for ensuring availability and education of resources (equipment, instruments, supplies) necessary to ensure positive patient outcomes. Completes variance review, analysis and action plans based on approved departmental budget. Performs cost analysis and works with physicians to reduce cost per case. Monitors clinical activities to reflect compliance with the ten stroke performance measures. Coordinates care/service delivery system to meet/exceed programs goals and objectives. Demonstrates leadership direction, mentorship and support coordination of all stroke patients. Demonstrates the ability to evaluate the effectiveness of patient, family and staff education on stroke care. Demonstrate responsibility for Quality/performance Dashboard/Scorecard and measurement activities that indicate progress towards facility, system/corporate and DNV performance measures for stroke goals. Develops and implements an effective and ongoing program that monitors outcomes, evaluates opportunities for improvement, and improves/integrates processes resulting in world-class patient care. Define quality metrics by
• Assess - Identifying the problem/process
• Plan - Measuring success at improving specific areas of patient care
• Design - Analyzing the root causes or variation from quality standards
• Implement - Improving the process with the evidence
• Sustain & Spread - Controlling solutions and sustaining success. Assures Quality Dashboard/Scorecard Measurements are indicative of progress towards stroke quality goals. Integrates department/facility operations and services with internal and external departments, to ensure care, policies, processes and services meet the needs of the community we serve. Maintains knowledge, affiliation/networks with professional/civic/service organizations that support professional development/relationships that align with the Mission, Vision and Values of RHS. Safety/Regulatory standards maintained and demonstrate progress and process improvement. Demonstrates respect, concern and empathy for patients/families/customers with diverse cultural and emotional needs. Demonstrates and ensure team understands and responds to suggestions and concerns from patients/visitors, personnel, medical staff and leadership. Strives continuously unit/facility activities to improve stroke service and patient care outcomes through the interpretation and maintenance of regulatory and accreditation standards in accordance with patient safety standards, standards of excellence and Rivers