Cardiac and Vascular Quality and Process Improvement Manager at Bryan Health – Lincoln, Nebraska

GENERAL SUMMARY:

Provides leadership for all activities related to regulatory compliance, registry participation, accreditation, process improvement and initiatives of the department. Demonstrates leadership skills and has expertise in a minimum of one realm of the quality department. Manages the department fiscal, material and human resources. Participates in performance improvement activities and division and organizational wide initiatives. Conducts research, provides information and supports the Cardiac and Vascular Service’s (CVS) organizational strategic plans and designated operational and clinical priorities for care directly affecting the organization's reimbursement, collected revenue and patient outcomes. Oversees performance process improvement initiatives for the Cardiovascular Service Line (CVSL). Facilitates the analysis and reporting of data which is abstracted from medical records, entered into appropriate databases and reported to medical staff, CVS clinical and ancillary staff, the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission.

PRINCIPAL JOB FUNCTIONS:

1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values.

2. *Supports regulatory, registry and accreditation activities.

3. * Meets or exceeds regulatory and accreditation standards.

4. *Provides leadership and participates in departmental and Medical Center improvement initiatives and teams as assigned.

5. *Provides oversight for the required clinical data retrieval, analysis and submission to external agencies to support quality improvement initiatives and compliance with regulations and standards.

6. *Serves as liaison with all internal and external departments for the monitoring, review and analysis of identified clinical quality, patient safety and process improvement projects.

7. *Presents data findings at quality improvement and medical staff meetings for identifying opportunities for clinical improvement.

8. *Maintains current knowledge of CMS program measures for payment determinations and Joint Commission requirements to ensure that accreditation and certification requirements specific to the cardiac service line are addressed on an ongoing basis.

9. *Coordinates Quality Improvement efforts influencing the cardiovascular department; works with director to ensure staff orientation, proficiencies and competencies; conducts meetings and education for staff.

10. *Recruits and manages staff to demonstrate behaviors consistent with Bryan beliefs and Bryan Core Values; acts as chief retention officer and oversees staff development for area of responsibility.

11. *Conducts timely staff performance appraisals assuring staff competence while emphasizing staff retention strategies through coaching and individual development.

12. Assures timely registry submissions and meets accreditation deadlines

13. Ensures that regulatory, accreditation and quality improvements are realized.

14. *Evaluates clinical and process improvement methodology for appropriateness and applicability.

15. Reports progress, results or barriers preventing successful implementation of projects to director.

16. Acts as a liaison between Organizational Quality, CVS, HIM and external data customer/vendors; contacts appropriate individuals with departmental questions/issues related to project work.

17. *Oversees the departmental budgetary procedure to ensure proper operational and capital planning; appropriate and efficient use of resources, and consistent compliance to budgetary and fiscal controls.

18. *Responsible for hiring, training, supervising, coaching, mentoring, retaining and evaluating of staff.

19. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.

20. Participates in meetings, committees and department projects as assigned.

21. Performs other related projects and duties as assigned.

(Essential Job functions are marked with an asterisk “*”. Refer to the Job Description Guide for the definition of essential and non-essential job functions.) Attach Addendum for positions with slightly different roles or work-specific differences as needed.

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:

1. Knowledge of NCDs, registry standards, and basic coding.

2. Knowledge of the principles of project management and change management.

3. Knowledge of publicly reported clinical quality and patient safety measures.

4. Knowledge of clinical and patient care-related processes.

5. Knowledge of medical and pharmacological terminology.

6. Knowledge of the principles and theories of process improvement, business management, statistical analysis, budgetary and financial methods and practices.

7. Knowledge of current process improvement methodologies and their application to healthcare.

8. Knowledge of organizational and human resource management standards and practices.

9. Knowledge of performance improvement, budgetary and financial methods and practices.

10. Knowledge of management and leadership principles and practices.

11. Knowledge of computer hardware equipment and software applications relevant to work functions.

12. Skill in supervising, mentoring, instructing and evaluating the work of professional staff.

13. Skill in conflict diffusion and resolution.

14. Ability to effectively interact and relate to a wide variety of employees, customers and external compliance representatives.

15. Ability to communicate effectively both verbally and in writing.

16. Ability to maintain confidentiality relevant to sensitive information.

17. Ability to lead teams/committees and work as a team member dependent upon role assignment and expectations.

18. Ability to promote change and facilitate systems thinking.

19. Ability to act in a proactive manner while also providing crisis/situational management in an erratic and potentially unpredictable work environment.

20. Ability to balance and prioritize diverse management and accreditation responsibilities.

21. Ability to perform crucial conversations with desired outcomes.

22. Ability to make operational and management decisions in response to changing conditions.

23. Ability to maintain regular and punctual attendance.

EDUCATION AND EXPERIENCE:

Bachelor’s degree in Nursing or a healthcare related field required. Master’s degree in Nursing, (MSN or Clinical Nurse Specialist), Health Care Administration or related field preferred. Minimum of five (5) years progressive experience in a clinical position with two (2) years supervisory or charge role required. Experience in a healthcare environment developing and implementing standards and process improvements required. Prior experience with regulatory and accreditation surveys preferred.

OTHER CREDENTIALS / CERTIFICATIONS:

None

PHYSICAL REQUIREMENTS:

(Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.)

(DOT) – Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.