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 FacilitationInitiates, 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
system. 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 comprehensiveAssesses program
accreditation program for the Mercy-Des Moines Central Iowa division.
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 leadershipEffectively
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
communicates activities and shared learning's vertically and
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.
the department budget effectively and determines fiscal requirements.
2. Prepares operating andParticipates as
capital budget recommendations.
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 aCollaborates with Risk Management to
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.
assure information used in analysis and process or performance
improvement enjoys the privacy and confidentiality protection afforded by
law.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
Understanding of both the acute care and
Multi-site leadership experience within a
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
Familiarity with the Magnet designation process