Market Director- High Reliability and Accreditation - Admini

Catholic Health Initiatives Des Moines, IA Closed
Catholic Health Initiatives is looking for Market Director- High Reliability and Accreditation - Admini in Des Moines, IA. This local job opportunity with ID 29593309 is live since 04/09/2019.

Job Summary / Purpose

This position manages Mercy Central Iowa accreditation
process across the region. Directs the
process as to regulatory compliance and preparedness. Leads a regional approach to compliance to
regulatory standards for Central Iowa hospitals and service line accreditation
processes. The Director facilitates all
aspects of regulatory compliance with regional leaders at facilities assigned,
including regular reporting to senior leadership the actual compliance to
standards and preparedness for surveys.
Acts as liaison between area of responsibility and the Quality
Division, vendors and user groups.
Additionally, this position directs and coordinate compliance with
regulatory requirements related to regional high reliability.

Essential Key Job Responsibilities

High Reliability Plan Facilitation

  • Initiates, oversees, and continuously
    evaluates a comprehensive High Reliability program inclusive of data
    analysis and opportunity identification.
  • Utilizing data from CHI and HPI, formulates high reliability
    principles based on best practices for Central Des Moines region.
  • Facilitates senior leadership oversight of the High Reliability
    Plan via design, implementation and reporting of quality and patient
    safety initiatives with accountability and distribution of organizational
    communication vertically and horizontally within the facility and the
  • In conjunction with
    medical staff leadership, directs and coordinates safety, quality and
    accreditation initiatives.
  • Serves as the
    liaison to the Regional operational leaders and the COO regarding
    regional based accreditation and high reliability plans and issues.
  • Establishes a
    climate that reduces obstacles and allows and promotes staff to formulate
    and practice own initiatives and perform at maximum achievement level
    utilizing Just Culture concepts.
  • Collaborates with
    colleagues to provide patient satisfaction, financial and other data to
    promote a balance review of High Reliability and patient safety
  • High Reliability Plan Facilitation

    1. Develops and oversees a comprehensive
    accreditation program for the Mercy-Des Moines Central Iowa division.

  • Assesses program
    compliance with accreditation standards and regulations related to
    clinical care in collaboration with facility leadership and staff.
    Identifies areas of vulnerability and directs the development of
    strategies to enhance compliance.
  • Coordinates hospital
    clinical compliance activities to ensure that hospital is in compliance
    with all required standards and has an integrated, consistent plan for
    continuously complying with all required CMS, Iowa State Statutes and
    Joint Commission standards.
  • Provides direction
    to hospital leadership in order to maintain readiness of assigned
    hospital(s) for all random and/or unannounced surveys by The Joint
    Commission, Iowa State Statutes and other regulatory agencies.
  • Proactively educates
    leadership and staff regarding new regulatory requirements related to
    quality and patient safety.
  • Reporting and Communication

    1. Works with medical and clinical leadership
    to organize, design and present reports on accreditation and patient safety
    initiatives. Identifies key point of
    variation or lack of reliability in processes and facilitates process

  • Effectively
    communicates activities and shared learning's vertically and
  • Conducts annual
    evaluation of program and provides Annual Report to Senior Leaders
    regarding patient safety and High Reliability Culture and outcomes.
  • Serves
    in the role of key liaison with marketing and IS in the submission and
    response to publicity reported data.
  • Management

    1. Manages
    the department budget effectively and determines fiscal requirements.

    2. Prepares operating and
    capital budget recommendations.

  • Participates as
    needed on key committees supporting quality and patient safety
    (Environmental Safety Committee, Quality and Patient Safety Councils,
    Tracers, etc.)
  • Maintains momentum
    of QPS activities. Utilizes the Chain of Command if progress on QA/QC/QI
    or patient safety initiatives is stalled.
  • Maintains strict
    confidentiality of information acquired in the course of duties.
  • Serves as a role
    model for the division principles (process focus, fact based decision
    making, and teamwork, non-punitive) and promotion of the culture of
    patient safety.
  • Performs other
    related duties incidental to the work described above in a professional
    and courteous manner.
  • Clinical Staff Peer Review

    1. Develops a
    Clinical Staff Peer Review process based on best practices and industry
    standards. Work with CHI andTrinity leaders to support current Peer Review processes that may exist at
    the System level.

  • Collaborates with Risk Management to
    assure information used in analysis and process or performance
    improvement enjoys the privacy and confidentiality protection afforded by
  • Serves as the key leader and facilitator
    of the Peer Review Process for the region of Central Iowa.
  • Utilizes Just Culture concepts in the
    review processes.
  • Identifies, trends and facilitates
    improvement in system issues related to findings.
  • Refers Employee practice issues to the
    appropriate leader and to HR.
  • Completes a quarterly summary of trends
    to Shared Governance counsel and works with directors on improvement
    action plans for the region on identified areas for improvement. Trains a
    staff level leader to chair the committee.
  • Develops and maintains a working charter
    and A-3 for this committee work.
  • Performs other position appropriate
    duties as required in a competent, professional, and courteous manner.
  • Required Bachelor's Degree in related discipline; Master's Degree strongly preferred.

    5-10 years of leadership or progressive
    leadership experience

    Understanding of both the acute care and
    ambulatory settings

    Multi-site leadership experience within a
    complex organization

    Project management, knowledge and
    application of quality tools and methods, working knowledge of key quality and
    regulatory agencies (JCAHO, IHI,), and strong speaking and presentation skills

    Current HRO certification or eligibility
    for certification within 12 months of hire required.

    Experience with process improvement and
    standardization efforts

    Familiarity with the Magnet designation process
    read more

    Required Skills

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