003907

This position reports to the Director of Quality and Safety, with a primary responsibility for the design, deployment, coordination, and active dissemination of a comprehensive set of a quality/process improvement strategies, operations, and tactics to advance care excellence at Abington and Lansdale Hospitals, and associated physician network practices, in alignment with Jefferson Health quality improvement initiatives.

1. Quality Improvement/Process Improvement education: With support from Director of Quality and Patient Safety designs, redesigns, and presents education/training programs meant to increase the organization's capacity and capability to learn and improve by embedding a programmatic approach to increasing the knowledge, skills, and attitudes of clinical improvement teams to achieve top performance patient care outcomes. Works with and coaches other leaders to prioritize and resource improvement work.

2. Quality Improvement (QI) Work: Independently leads inter-professional teams, facilitates change, utilizing change leadership , change management, and process improvement skills (e.g., process mapping, value stream mapping, project management, workout facilitation, data analysis and data visualization) to conduct value stream design and redesign work to advance goals in key initiatives, listed here:

• AH/LH key scorecard and prioritized non-scorecard QI improvement work to achieve targets.

•Pay for Performance (HAC, VBP, HRRP) programs, and Transparency programs (CMS Stars, Leapfrog, USNWR, Hospital Compare).

•Patient Experience and Equity measures

3. Quality Assurance:

• Programmatic Approach: leads the design, deployment, monitoring and maintenance, of a programmatic approach to Quality Assurance, as defined by CMS (QAPI program). Assures data-based decision making for all quality assurance improvement initiatives. Applies project planning techniques for all initiatives.
• Surveillance: Conducts clinical record review in conjunction with area Directors and Managers for monitoring Quality and Safety data collection and reporting. Performs audits and chart reviews as appropriate to validate data.
• Leads and coordinates the Abington Hospital and Lansdale Hospital response for the annual Leapfrog survey, identifies gaps, and maintains a gap analysis with action plans
• Collaborates to ensure Joint Commission readiness, especially with standards in the NPSG and Performance Improvement chapters, and preparation for data review sessions
• Collaborates and supports other departments for all specialty certifications (e.g., Magnet, Pathways to Excellence, cardiac, stroke, VAD, etc.)
• Collaborates with others to ensure compliance with all CMS, TJC, DOH quality assurance and quality improvement requirements and standards.
• Leads, oversees and ensures compliance with submission of appropriate quality measures to CMS and TJC for Abington Hospital and Lansdale Hospital (e.g., Inpatient, Outpatient, Inpatient Psychiatric, Maternal, and eCQM programs). Acts as Security Official for CMS measure platforms and TJC Direct Data Submission platform. Ensures tracking, documentation, validation, and communication for all programs.
• Maintains files for the hospitals of all CMS safety and quality reports; analyzes results and communicates findings to appropriate leaders, departments, and committees.
• In partnership with Regulatory, Medical Staff Office, Patient Experience and Risk Management leadership, ensures compliance and facilitates responses to quality of care concern inquiries from insurance companies, TJC, DOH.

Qualifications

Education:

Bachelor's degree required. Master's degree preferred. RN, or other healthcare related discipline or equivalent experience in an acute care hospital.

AND

Experience:

3+ years experience in Patient Safety/Quality Improvement in a supervisory level or project leader status strongly preferred. Clinical experience preferred.

Closing Statement

Jefferson includes Thomas Jefferson University and Jefferson Health, a dynamic university and health system with broad reach across the Delaware Valley. Jefferson is the second largest employer in Philadelphia and the largest health system in Philadelphia based on total licensed beds.

Through the merger of Thomas Jefferson University and Philadelphia University in 2017, our University includes ten colleges and four schools. We are an NCAA Division II university and an R2 national doctoral university offering undergraduate and graduate-level programs that provide students with a forward-thinking education in architecture, business, design, engineering, fashion and textiles, health, medicine and social science.

Jefferson Health, the clinical arm of Thomas Jefferson University, has grown from a three-hospital academic health center in 2015, to an 18-hospital health system through mergers and combinations that include hospitals at Abington Health, Aria Health, Kennedy Health, Magee Rehabilitation and Einstein Healthcare Network. We have over 50 outpatient and urgent care centers; ten Magnet®-designated hospitals (recognized by the ANCC for nursing excellence); the NCI-designated Sidney Kimmel Cancer Center (one of only 70 in the country and one of only two in the region); and one of the largest faculty-based telehealth networks in the country. In 2021, Jefferson Health became the sole owner of HealthPartners Plan, a not-for-profit health maintenance organization in Southeastern Pennsylvania. We are the first health system regionally to create an aligned payer-provider partnership.

Jefferson's mission, vision and values create an organization that attracts the best and the brightest students, faculty, staff, and healthcare professionals, as well as the most visionary leaders to drive exceptional results.

• OUR MISSION: We improve lives.
• OUR VISION: Reimagining health, education and discovery to create unparalleled value
• OUR VALUES: Put People First, Be Bold & Think Differently and Do the Right Thing

As an employer, Jefferson maintains a commitment to provide equal access to employment. Jefferson values diversity and encourages applications from women, members of minority groups, LGBTQ individuals, disabled individuals, and veterans.

Par Reference Code

106227