Description

US:NV:Carson City Quality Management

Full Time Day Shift

About Carson Tahoe Health

CTH is a not-for-profit healthcare system with 240 licensed acute care beds, fully accredited by the Center for Improvement in Healthcare Quality (CIHQ). CTH was voted 5 th most beautiful hospital in the nation nestled among the foothills of the Sierra Nevada in North Carson City and only a short drive away from world-famous Lake Tahoe & Reno. We serve a population of over 250,000 and feature two hospitals, two urgent cares, an emergent care center, outpatient services and a provider network with 19 regional locations.

Summary

Responsible for planning designing, implementing, and evaluating the performance improvement programs and continuous quality improvement activities to meet the needs of Carson Tahoe Health System. Acts as resource person to Health System administrative teams, department managers, and medical staff. Oversight responsibility for all regulatory body surveys, such as, CIHQ, State Licensing Review, HCFA (CMS) Validation surveys. Maintains oversight responsibility for all quality performance improvement activities conducted throughout the Health System. The goals of this position are to improve patient outcomes and healthcare delivery through the establishment of an integrated and collaborative Health System approach to performance improvement; reduce the incidence of potentially adverse events through the establishment and compliance to aggressive and comprehensive patient quality programs; and, to provide for the most efficient use of clinical resources in the pursuit of quality patient care.

Responsibilities

• Coordinates and facilitates all Quality Improvement (QI) activities throughout the Health System. Oversees the development of all QI functions, ensuring these functions are conducted in accordance with regulatory guidelines and prioritized risk assessments. • Works collaboratively with various System administrative/management/staff, Chief Medical Officer (CMO), Medical Staffs/Chief of Staff/Chairs/Medical Directors on QI initiatives, and supervises the development of data-driven action plans to guide quality improvement. • Supervises the development of reports for QI initiative dissemination. Collaborates with the CMO for reporting quality performance throughout the Health System. Ensures performance feedback is provided under the direction of the CMO, to the appropriate Health System staff / management / administrative / governing bodies. • Oversees the development and methodologies for data abstraction, report builds, data analysis, and data display in conjunction with the Director of Business Intelligence. • Ensures that all quality improvement operations conform to the principles of CQI/Plan-Do-Check-Act (PDCA) and Lean methodologies. Provides training on these concepts. • Monitors and audits internal procedures proactively for safety risks, conducts process flow charting to improve process safety/reliability/quality. • Ensures all contracted deliverables for the Quality and Outcomes Management Department are achieved. • Directs the quality programs for quality assessment and improvement, accreditation and regulation licensing, and compliance by developing, updating, implementing, and ensuring compliance with System Quality Improvement Plans. • Leads regulatory compliance to maintain accreditation status and/or attain accreditation/certification status. • Works closely with Risk Management/Patient Safety Officer/Quality staff to address patient care issues/sentinel events through internal investigation/Root Cause Analysis. Ensures activities eradicate safety risks via identification of root cause, process flow charting/process flaw identification, and targeted action plans to resolve and prevent future events. • Collaborates with the Patient Safety Officer for automated occurrence/peer review systems and data trends produced from these systems. • Collaborates with leadership, departments, clients, and community in designing processes, tools and templates that continually improve the quality, efficiency, service and effectiveness of care and service; consults and participates in performance improvement teams using a variety of methodologies; serves as a critical link in the identification and resolution of issues, which affect the Health System image. • Collaborates with the Medical Staff in overseeing the Quality Department's successful processing of chart reviews, data collections, and reporting for peer reviews, collaborate with Medical Staff Services for timely completion of Ongoing Professional Practice Evaluations, Focused Professional Practice Evaluations, and Appointment/Reappointment profiles. • Attends Medical Staff Committee/Section meetings for both closed/open sessions. Attends/assigns appropriate Quality representation at System committees. • Prepares for surveys and inspections, including educational forums, coordinating mock surveys and assessments, assists in developing response plans. Interprets and assists in planning responses to new or changing regulations or standards. Serves as the primary contact and liaison with organizations like CIHQ, and other state and federal regulatory agencies. • Develops, implements, and meets the established financial goals. Monitors applicable budget, and identifies and supports solutions to reduce cost structure. Manages vendor contracts related to the Quality department. • Performs other related duties as assigned.

Qualifications

• Required o Bachelor level degree in an applicable healthcare or business field. o Minimum of five (5) years acute care hospital experience in quality improvement theories, reporting, and practices. o Working knowledge of CIHQ, CMS, State and other compliance standards. o o Proven performance in the ability to gather, analyze, and make recommendations based on complex and diverse data. Knowledge of techniques to include: root cause analysis, cause and effect analysis, failure mode and effects analysis, and development of action plans. • Preferred o Masters level degree in an applicable healthcare or business field. o Certified Professional Healthcare Quality (CPHQ) or Green Belt Six Sigma. o State of Nevada Registered Nurse licensure or Interim Permit. o Previous leadership experience; in a Quality & Risk Management department setting preferred.

Top 5 Reasons to Live in Carson City, Nevada

• Live, work and play in one of the most beautiful regions in the world
• Enjoy an array of outdoor activities world class skiing, golf, camping, mountain biking, hiking, water skiing, kayaking, hunting and fishing
• Just next door is Beautiful Lake Tahoe
• We are minutes from Reno known as the 'biggest little city in the world' - Fine dining, nightlife, shopping and home to the University of Nevada Reno.
• Family friendly atmosphere with affordable housing & excellent school system

Our Benefits

• No State Income Tax
• Medical, Dental, Vision, FSA, Telehealth
• Paid Time Off, Mental Health, and Volunteer Days
• 100% Vested 401K & Roth with Company Contribution
• Tuition Reimbursement
• Referral Bonuses
• On Site Education & Certification Programs
• Base Wage Increases for Relevant Advanced Degrees
• Free Calm App Subscription