At Carolina Pines Regional Medical Center, we recognize that our patients deserve qualified, engaged, and competent healthcare professionals. And we know that our employees deserve a working environment that is safe, leaders who are visible and supportive, and opportunities to grow and develop. We have a positive, hopeful, and resilient leadership team that is solely focused on taking care of the heart of Carolina Pines – the people who work here. If you feel that your skills and compassion fit with our vision for person-centered care and evidence-based practice, and you would like to belong to a hospital family that only the best are invited to join, we invite you to apply today.

Under the direction of the VP of Physician Services, Chief Medical Officer, and Director of Quality, the incumbent will oversee the ambulatory quality and data analytics teams who are accountable for meeting metrics and reporting data for annual quality programs.

1. Develop and implement a comprehensive ambulatory quality improvement strategy aligned with the health system's mission and goals.
2. Provide leadership in establishing quality goals, performance benchmarks, and standards for ambulatory care. Collaborate with senior leadership, medical directors and department heads to integrate quality initiatives into overall health system strategies.
3. Oversees the ambulatory quality improvement team who is responsible for helping clinics design, implement and monitor quality improvement interventions
4. Helps to design, develop and manage the Quality Improvement and Population Health Department services and deliverables, including clinical programs related to quality improvement, population health, clinical safety and other health service initiatives.
5.  Design, implement, and monitor quality improvement programs that enhance patient outcomes and service delivery in ambulatory settings in collaboration with Ambulatory operational and clinical leadership.
6.  Utilize data analytics to identify areas for improvement and track the effectiveness of quality initiatives.
7. Promote the use of evidence-based practices and clinical guidelines to ensure high standards of care.
8. Ensure compliance with all relevant regulatory and accreditation standards, including those set by The Joint Commission, CMS, and other governing bodies.
9.  Lead preparations for accreditation surveys and audits, ensuring readiness and adherence to required standards. Stay current with changes in regulatory requirements and implement necessary adjustments to maintain compliance.
10. Develop and maintain a robust performance measurement system, including key performance indicators (KPIs) for ambulatory quality.
11. Prepare and present regular reports on quality performance to senior leadership, highlighting successes and areas needing improvement.
12. Lead efforts to publicly report quality data, ensuring transparency and accountability.
13. Develop and implement training programs for clinical and administrative staff on quality improvement methodologies and best practices. Provide mentorship and leadership development opportunities for quality improvement staff. Encourage a culture of continuous learning and professional development.
14. Facilitate effective communication and collaboration among multidisciplinary teams to promote a unified approach to quality improvement. Work with Patient Safety, Infection Prevention, Patient Experience, and Hospital Quality based teams to achieve system goals. Engage with patients and families to understand their perspectives and incorporate their feedback into quality initiatives.
15. Represent the health system in external quality improvement networks and professional organizations.
16. Oversees a large and diverse ambulatory quality improvement team responsible for helping AC clinics design, implement, and monitor quality improvement interventions.
17. Oversees Ambulatory patient safety efforts, including incident reporting and patient grievances.
18. Manage the budget and resources allocated for ambulatory quality initiatives. Ensure efficient use of resources and seek opportunities for cost-effective improvements in quality.
19. Optimize MIPS, MACRA, Medicare Advantage, ACO, PCMH and other quality metric utilization through researching CMS requirements, rewards, and consequences.
20. Oversees the selection and implementation of technology and tools that support quality improvement efforts.
21. Provides leadership in overseeing improvements in data analytics processes to develop timely, actionable data. This encompasses both data for quality improvement as well as operational data to guide business decisions such as expansion, capital investment, and other strategic planning;
22. Supervises the highly technical ambulatory care analytics team, including both technical oversight of their work as well as high level project planning;
23. Coordinating relationships with clinical and social service agencies and documenting protocols for agency communication and referrals pertaining to quality improvement activities.
24. Assisting the VP of Physican Services, Quality Director and CMO in managing quality programs, including MIPS, HEDIS and other regulatory reporting requirements.
25. Works with the Director Hospital Quality to ensure ambulatory settings understand and meet with the greatest efficiencies regulatory standards when transitioning patients to hospitals.

26.  Ensure compliance with Patient Care, Infection Control, OSHA, DHHS, CMS, and other regulatory standards, policies and procedures.

27.  Focuses on better healthcare value and quality, including the improvement of clinical outcomes, patient experience, patient safety, cost, revenue, productivity, efficiency, employee and physician satisfaction, and process reliability.

28.  Develop curriculum and training to promote clinical excellence among clinical staff.

29.  Other projects as assigned.

MANAGEMENT  DUTIES

1.      Assist in the formulation of targets for individuals and teams.

2.     Answer questions from staff and provide guidance and feedback

3.     Anticipate escalation and take over calls when needed

4.     Devise ways to optimize procedures and keep staff motivated

5.     Measure performance with key metrics.

6.     Ensure adherence to policies for attendance, established procedures etc.

7.     Assists with taking calls when call volumes are above normal, during peak call volumes

8.     Keep management informed on issues and problems

9.     Prepare monthly/annual results and performance reports to analyze and improve processes

10.  Knowledge of multi-line phone system.

11.  Proficient in computers and relevant software applications and practice management technology including electronic recordkeeping.

12.  Knowledge of customer service principles and practices.

13.  Demonstrated initiative and strong organizational skills.

14.  Exceptional interpersonal communication skills with a positive tone.

15.  Ability to work independently on assigned tasks as well as to accept direction on given assignments.

16.  Deals with confidential information and/or issues using discretion and judgment.

ORGANIZATIONAL EXPECTATIONS:

1. Provides a positive and professional representation of the organization.
2. Promotes a culture of safety for patients and employees through proper identification, reporting, documentation, and prevention.
3. Maintains competency and knowledge of current standards of practice, trends, and developments in related  scope of role or practice.
4. Maintains compliance with organization's policies, as well as established practices, protocols and procedures of the position, department, and applicable professional standards.
5. Complies with organizational and regulatory policies for handling confidential patient information.
6. Demonstrates excellent customer service through his/her attitude and actions, consistent with the standards contained in the Vision, Mission, and Values of the organization.
7. Adheres to professional standards, hospital policies and procedures, federal, state, and local requirements and the TJC standards and or standards from other accrediting bodies.

COMMUNICATIONS/COLLABORATION:

1.     Reports practice feedback, barriers, progress, and results of improvement initiatives to VP of Physician Services, CPMG Practice Managers, and appropriate workgroups.

2.     Recognizes and seeks to resolve negative situations that disrupt organizational/departmental harmony.

3.     Demonstrate empathic listening skills, potential problems and effectively participate in their resolution.

4.     Other duties as assigned.

·       Qualifications: RN Required.

·       Experience:    Five (5) years of recent and progressively responsible experience in healthcare administration, leadership, and management.

·       Three (3) years supervising professional-level technical staff. 

·       Familiarity with Lean, Six Sigma, and other quality improvement frameworks.

·       Familiarity with the regulatory and programmatic aspects of healthcare complaints and grievances.

·       Extensive experience in ambulatory (physician clinic) operations.

·       Experience in ensuring compliance with regulations and standards.

·       Experience with Healthcare Quality measurement, reporting and data analysis.

·       Extensive experience with Meaningful Use, PQRS, and other quality reporting to help the organization be successful in MIPS, MACRA, Medicare Advantage regulations, ACO or other quality reporting programs.

·       Training & presentation experience.

·       Experience in deploying clinical quality improvement programs

·       Highly skilled in Excel, Data Extraction, PowerPoint

About Carolina Pines Regional Medical Center

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