Coordinates regulatory compliance, performance improvement, and risk reduction initiatives/processes for a clinical service line or regional function at all locations to address and strengthen patient safety, utilization of clinical resources, and achievement of desired clinical outcomes that facilitate achievement of overall financial goals and business/patient satisfaction objectives. Incumbents serve as project manager for a variety of management-level work teams, providing support, expertise, quality literature, theories of innovation and guidance in: 1) the application of accepted clinical quality improvement methodologies/tools; 2) data collection and statistical/operational analysis; 3) outcomes measurement; 4) risk assessment and reduction measures; 5) research and establishment of best practices; 6) documenting and implementing process improvements; 7) evaluating desired vs. actual clinical effectiveness, reporting outcomes at monthly Quality Assurance Performance Improvement meetings at each location, of performance improvement efforts and; 8) working with clinic staff to ensure survey readiness.
Incumbents are also accountable for maintaining current skills/knowledge of new clinical procedures/processes, patient care standards/practices, new/changing regulatory requirements, departmental policies/standards/procedures, patient safety goals and Joint Commission standards impacting matters within designated scope of responsibility; ensures that these factors are considered and integrated into performance improvement activities
Performs “rounds” to evaluate, analyze and access patient care activities in relation to FHS standards of care and applicable regulatory requirements specific to the assigned service line/function at all locations.
Ensures full compliance with Joint Commission accreditation, Washington State Department of Health (DOH), and other safety-related standards, rules and regulations for purposes of improving healthcare delivery, increasing productivity/efficiency, improving clinical outcomes and enhancing patient safety.
Analyzes and assesses clinical practices (e.g. “audits”) for opportunities to improve healthcare delivery, increase productivity/efficiency, improve clinical outcomes and enhance patient safety for assigned department.
Collects/analyzes relevant data; uncovers root causes; develops performance/process improvement plan and implementation strategy.
Identifies quality/performance improvement opportunities and recommends strategies and practices to increase productivity/efficiency, improve clinical outcomes and enhance patient safety.
Plans and conducts internal reviews/audits to ensure that department operations are conducted in compliance with all regulatory requirements/guidelines.
Develops appropriate audit tools to measure compliance.
Identifies non-compliance issues/concerns causes thereof, risk exposures and recommends necessary, effective and adequate corrective action. Develops/implements effective tactics/solutions to address and resolve issues/concerns.
Identifies and validates evidence-based best practices in clinical practice and patient safety to guide clinical areas in performance improvement activities and to ensure current credentialing in specialty area is sustained; researches nature/scope of impact on existing activities and makes appropriate recommendations.
Participates in the development, evaluation, implementation and ongoing maintenance of policies, standards, procedures and automated tools that support FHS goals and department-specific objectives/initiatives; serves as department representative on cross-functional and interdisciplinary teams as assigned.
Provides continuing assistance to management with respect to the development and/or improvement of existing clinical/treatment protocols/practices through the ongoing observation, analysis and evaluation of current activities; monitors and evaluates results achieved in relation to objectives.
Addresses risk management and regulatory issues/concerns relating to the assigned service line/function. Investigates and responds to grievances and patient complaints directly.
Researches and develops formal responses to citations/findings.
Participates in the development/implementation of action plans that address risk management/safety issues specific to the assigned department, and monitors adherence thereto; identifies continuing issues and works with Risk Management staff to resolve.
Depending on assigned department, may investigate and respond to grievances and patient complaints directly and/or refers them to appropriate internal resource (e.g. Patient Advocate); follows up to ensure issues are responded to and documented in a timely and professional manner and are consistent with FHS service recovery standards.
Education/Work Experience Requirements
Bachelor’s degree in nursing or applied science, plus five years of progressively responsible related work experience that demonstrates the attainment of the requisite job knowledge, skills and abilities. Depending on the assigned department, specialized work experience is strongly preferred.
Internal Number: 1515
About St. Joseph Medical Center
Job Summary:This job is responsible for managing the day-to-day clinical operations of an assigned division of the Franciscan Health System (FHS) Hospice consistent with service line objectives, standards of patient care/practice, safety/risk management guidelines and applicable regulatory requirements. An incumbent may be assigned to one of six divisions/facilities (e.g. King County, Pierce County [East or West], Care Facilities, End-of-Life, Access, Hospice House or Palliative Medicine) and although core responsibilities will be the same, the specific assignment may involve some differences in job duties. Work includes: 1) ensuring that overall goals relating to productivity, quality of care, patient satisfaction and/or growth in market share are achieved; 2) developing/implementing/monitoring quality improvement initiatives to enhance/streamline current procedures/processes and to ensure programs/services meet accrediting standards for the Joint Commission on Accreditation of Health Organizations (JCAHO) and other accrediting agencies; 3) performing ongoing performance improvement activities (e.g. service recovery, identifying/responding to negative quality trends, ensuring su...rvey readiness) and 4) managing/developing clinical staff in the delivery of patient care and related support services.As a key member of the Hospice/Palliative management team, an incumbent participates in long-range planning, budget administration and in formulating operational approaches, tactics and policies to facilitate achievement of strategic business objectives. Work requires considerable understanding of the standards of nursing practice, as well as regulatory requirements pertaining to hospice facilities and care. Essential Duties:Operations:Manages and evaluates the operations, programs and resources of the assigned clinical division to assure the safe and appropriate delivery of diagnostic and therapeutic patient care, achievement of clinical core measurement scores, and to ensure that all activities are conducted in a timely and cost-effective manner and in compliance with organizational values, professional standards, collective bargaining agreements, internal policies/standards/procedures and applicable regulatory requirements; analyzes/coordinates care provided through the efforts of an interdisciplinary team (IDT); participates in the development of, and implements new clinical protocols/programs to enhance existing services and raise the standard of care for the patient population served; ensures that work unit activities, productivity, and/or quality indicators are documented in accordance with FHS guidelines; ensures that patient Plans of Care are coordinated with the facility staff, and that documentation is appropriate to facilitate proper reimbursement and to meet audit/regulatory requirements; produces and presents reports on key performance indicators and other significant benchmarking metrics; collaborates with other departments to address and resolve problems, share information and enhance overall effectiveness/productivity. Recommends, implements and evaluates new/revised protocols, procedures, guidelines, training materials and/or general communications in support of assigned clinical area/facility to ensure consistency with the philosophy/values of the organization and compliance with applicable regulatory/accreditation requirements; reviews training materials prior to assimilation into training curricula; ensures that all clinical and related support activities are fully documented in accordance with the standards/practices of the organization; ensures that employees understand and apply internal guidelines appropriately, and monitors compliance with all regulatory requirements. Staff Management and Development:Plans, manages and evaluates the work of clinical and administrative staff engaged in the evaluation/admission of patients, the delivery of patient/nursing care and/or the coordination of clinic/community services to the terminally ill and their families in accordance with the content, spirit and intent of applicable internal/external regulations and standards for human resource management; identifies adequate staffing levels for appropriate coverage to meet budgetary and operational objectives; ensures that employees are qualified and properly trained to perform assigned job duties; holds regular staff meetings and keeps employees appraised of all matters relevant to successful job performance; makes employment decisions, establishes performance standards and evaluates employee performance; educates, guides, counsels and develops staff and addresses performance management concerns and technical issues elevated by subordinates as beyond their scope of authority.Oversees and coordinates the professional development and growth of assigned staff through in-service training and ongoing education; identifies staff training needs by performing chart audits, and analyzing performance outcomes and trend reports (e.g. Occurrence Reports, Patient Grievance Forms, etc); demonstrates awareness of, and ensures that staff follow, established departmental policies/procedures and quality improvement, safety, environmental and infection control standards. Short- and Long-Term Planning:Participates, as a key member of the management team for the assigned clinical function, in the development of strategies, initiatives and programs addressing matters such as: provision of new services, standardization of procedures across the organization, increasing market share, maximizing resources, cross-selling services, improving cost-effectiveness of clinical services provided, enhancing patient outcomes/satisfaction and other issues of similar complexity and consequence. Performance/Quality Improvement:Works with management team to ensure the application of consistent practices relating to internal operations, patient care, quality of human resources activities and FHS standards; assesses the strengths/weaknesses of the assigned clinical area/facility to identify opportunities and provide recommendations to Director for new quality/performance improvement initiatives (e.g. streamline operations, address patient care and facility operations, improve workplace environment, increase caregiver/physician satisfaction, etc); implements new processes and ensures that performance improvement activities are conducted in a timely and effective manner; ensures that staff receive the necessary on-site training and consultation to enhance their understanding of quality/performance improvement initiatives. Regulatory Compliance:Follows established guidelines to ensures that all aspects of clinical operations are conducted and documented in compliance with relevant internal policies, standards and procedures and applicable regulatory requirements; assesses, on a continuous basis, services, patient outcomes, quality control, family/patient satisfaction, staffing needs and operational effectiveness to ensure optimal care delivery; ensures that internal controls are sufficient to provide for accurate, complete and compliant programs and processes; identifies need for changes in standards, programs and services, and develops recommendations for consideration by the Director. Keeps abreast of changing regulatory requirements/regulation, clinical/professional standards, changing customer demographics and competitive industry practices impacting assigned functions, as well as organizational initiatives/changes with potential to impact current strategies, programs and resources; determines nature/scope of impact on existing activities and determines effective response/solution while maintaining acceptable service levels and work quality. Other Essential Duties:Participates in the maintenance of professional relationships between Hospice and facility administration through periodic review of facility contracts/clinical service agreements and direct meetings with facility leadership; responds promptly to facility customer service issues; provides feedback to the Hospice Director regarding cost/quality issues.If assigned to King County:Manages the activities of a administrative office located in King County set up to establish a physical presence in the geographic area and to provide space for field staff to perform administrative activities (e.g. make phone calls, prepare documentation, etc). CHI Franciscan Health has exciting and rewarding careers with competitive salaries and benefits. We are a family of hospitals, health care services, and medical providers delivering compassionate care to people throughout the South Puget Sound. We are part of Catholic Health Initiatives, one of the largest not-for-profit health care systems in the country.Job Requirements: Graduation from an accredited school of nursing, BSN strongly preferredFive years of recent RN work experience in an acute clinical setting (e.g. Med/Surg, Home Health or Gerontology) that would demonstrate attainment of the requisite job knowledge/abilities, including a minimum of two years in a lead or supervisory capacity. Two years work experience as a Hospice RN is strongly preferred. Current licensure as a Registered Nurse by the Washington State Board of Nursing. Current healthcare provider BLS certification.Consistent with our Core Values, Catholic Health Initiatives employers are EEO/AA/M/F/Vets/Disabled Employers. Qualified applicants will receive consideration for employment without regard to their race, color, religion, national origin, sex, sexual orientation, gender identification, protected veteran status, disability or any other legally protected characteristic.