The Director has responsibility for Quality and Regulatory programs for CHRISTUS Trinity Mother Francis hospital, Jacksonville Critical Access hospital, and associated outpatient sites. Key responsibilities include establishing programs and processes that support stakeholders from both acute and ambulatory Ministries to address the requirements of agencies such as CMS (Medicare), National Quality Forum (NQF), National Healthcare Safety Network (NHSN), The Joint Commission (TJC), National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data and Information Set (HEDIS) and more. This leader utilizes content expertise for quality reporting, data analytics and project management to ensure an accurate and timely response to all quality and regulatory programs inquiries.
The successful Director will require knowledge and expertise about the use of application tools such as, Midas, Epic, Epic, MicroStrategy, Vigilanz and other quality application tools. This position will report to the Regional Director of Quality and work in partnership with the Chief Medical Officer, Chief Nursing Officer, and Associate Vice President of Quality & Safety for Northeast Texas. The leader will ensure the Ministries under charge will meet or exceed the high quality and performance goals set for all Ministries in the CHRISTUS Health Ministry.The Director will ensure the department performs impact analyses of emerging or changing quality program changes and emerging regulations. The Director willhave a global view of the organizationand continually drive towards CHRISTUS Health Mission of 'Zero Harm' and bring high-reliability processes and information governance strategies to the performance of job responsibilities.
A successful candidate will be a proactive and decisive person who adapts well to multiple competing priorities and balances the priorities of the organization with the activities of the department. Additionally, this role serves at the forefront of regulatory and accreditation success for the hospitaland perform duties and responsibilities in a manner consistent with CHRISTUS Health Mission, Values, and Service Standards.
MAJOR JOB RESPONSIBILITIES
Public Reporting and Value Based Imperatives:
A. Drives value-based initiative integration, reporting, and taskforce needs of CHRISTUS Health, including Joint Commission Standards, CMS Regulations and State Regulations in partnership with Ministry Quality & Regulatory leaders to provide consistent processes across the CHRISTUS Health Ministries.
• Leads, directs and organizes multidisciplinary teams, under the oversight of the Regional Quality Director of Quality, for high reliability, ongoing regulatory compliance, and continuous quality improvement.
• Supports production of reports in collaboration with subject matter experts.
B. Proactively monitors national regulatory initiatives and develops impact analysis for CHRISTUS Health, including close collaboration with Information Management teams to enhance or develop new tools for stakeholders in addressing initiatives.
C. Oversees and coordinates the data and profile development processes for regulatory accreditation including support data for hospital staff for a constant state of readiness, compliance with standards, and promoting a culture of safety.
D. Provides Ministry wide advice on National Imperatives, regulatory and quality changes in reporting of metrics for CHRISTUS Health hospitals and providers to guide necessity, impact for modification and/or development of process improvement efforts.
A. Serves as internal and external stakeholder point of contact for regulatory related initiatives and ad hoc analyses to address inquiries & resolve anomalies.
B. Communicate to key stakeholders via a comprehensive, standardized format detailing the methods, analysis and conclusions, and recommended next steps.
C. Develops reports to effectively convey regulatory updates from appropriate data sources and systems, including national benchmarks and public ranking data.
• Responds to regulatory bodies with action plans and measures of success
• Tracks and organizes regulatory activities
A. Demonstrates a commitment to self-improvement as a leader by actively developing the Leadership, Professional and Technical competencies assigned.
B. Has effective development plans for a growing team of associates.
C. Continuously evaluates and maintains chosen application tool(s) for alignment with regulations within the CHRISTUS Health System Office:
• Alignment with value based imperative metrics
• Consistency with data governance definitions and processes
Performs all duties in a manner that protects the confidentiality of patients and does not solicit or disclose any confidential information unless it is necessary in the performance of assigned job duties.
•Bachelors degree in nursing preferred
•MBA, MHA, or Advanced degree (Masters or higher) in related field required. •Demonstrated competency in value-based initiatives and healthcare application tools required •Strong working knowledge of regulatory standards for acute and ambulatory care settings (NHSN, NDNQI, CMS: IQR, IPPS, VBP, RRP, HAC, etc.) •Computer literacy (Microsoft Office, healthcare analytic applications, such as MIDAS+, and communications tools, such as SharePoint) •Ability to develop effective presentations and reports for leaders
•5+ years of experience managing quality outcomes, large disparate data sets, including CMS data and using quantitative and qualitative analysis to draw meaningful and valid insights, including 3+ years of programming experience using analytic software, such as Excel/SAS/SQL/Python/R. •Previous experience facilitating teams or leading projects •Strong communication skills (both oral and written) •Excellent prioritization, organizational and program management skills •Must be able to present results to senior leadership and region stakeholders •Must be a team player and be willing to collaborate and assist with members of the team as necessary.
C. Licenses, Registrations, or Certifications
Vizient, Premier, or Midas+ System Administrator certification preferred