System Director Img Quality

St Mary's Health System Tewksbury , MA 01876

Posted 2 months ago

Summary # The System Director of Integrated Medical Group (IMG) Quality is responsible for overseeing the provider practice quality programs across the system. Directs a comprehensive and unified quality program across Covenant provider practices. Responsible for implementing, tracking and monitoring IMG ambulatory quality metrics and recommending quality improvement interventions. Maintains and systematically evaluates the quality and effectiveness of the system-wide program. Facilitates the systematic collection and analysis of quality data to identify trends. Serves as educational resource on quality and regulatory programs providing expert knowledge and guidance. Provides consultation to interdisciplinary team members as needed. Facilitates a continuous state of readiness surrounding accreditation and certification programs. # Essential Duties and Responsibilities Integrates the principles and values of continuous quality improvement (CQI) throughout IMG. Promotes the relevance and use of CQI tools (e.g. process maps, cause and effect diagrams) for ambulatory quality performance and patient experience improvement efforts# Monitors and compiles ambulatory quality performance metrics required for regulatory and recognition programs (e.g. MACRA, MU, PCMH), investigates underperformance and offers improvement recommendations. Monitors patient experience survey results and stays current on various quality and patient experience program changes; provides education and training to key stakeholders Ensures that process improvement efforts comply with regulatory and accreditation standards. Advises on accreditation and ISO requirements. Advises on future data and information needs and resources to better support performance and process improvement initiatives. Uses change management processes to engage others in support of the changes required to achieve performance improvement outcomes. Collaborates with practice administration, physician leadership, information services, risk management, care coordination and medical affairs to ensure optimal performance and mitigate issues Assists with audits of medical staff for compliance with policies and procedures and with regulatory and accreditation requirements. Collaborates with CMIO and IT staff to ensure data systems and programs satisfactorily support CQI activities, including maintaining QI tracking systems and database. Participates in significant departmental initiatives. Maintains collaborative team relationships with peers and colleagues. Directly oversees the market IMG Quality Managers. Supports and promotes the mission and values of Covenant Health and the Catholic Health Ministry. Other duties as consistent with this role. # Job Requirements # Education # Experience

####Bachelor

#s degree in health care field required; Master#s degree preferred. CPHQ certification, or eligible to obtain within 1 year. Minimum of five years of experience in health care setting including three years of

####management

/QI experience performing oversight activities or quality improvement. # Job knowledge and skills Demonstrable commitment to the highest standard of ethical and professional conduct Demonstrates expertise in data management and the use of analytical and statistical tools to identify trends in current processes and systems. Skill in effective application of CQI teams, quality measures, clinical guidelines, and process management initiatives. Skill in consistently meeting reporting requirements of NCQA, HEDIS, CMS, ACO and other regulators and accreditors. Outstanding organizational and project management abilities. Computer skills in Microsoft Office (Word, Excel, Access, PowerPoint and Outlook) for email, scheduling, and navigation of the organization#s computer systems. Excellent verbal/written communication and interpersonal skills; skilled in facilitation, presentation and negotiation. Skill in using system software effectively to produce trend analysis, evaluation data, and documentation. Analytical and problem-solving skills and excellent judgment a must Ability to work under pressure and challenging deadlines and adaptability and flexibility required. # # Covenant Health Mission Statement We are a Catholic health ministry, providing healing and care for the whole person, in service to all in our communities.


Our Core Values:


#Compassion We show respect, caring and sensitivity towards all, honoring the dignity of each person, especially the poor, vulnerable and suffering. # #Integrity We promote justice and ethical behavior, and responsibly steward our human, financial and environmental resources. # #Collaboration We work in partnership, dialogue and shared purpose to create healthy communities. # #Excellence We deliver all services with the highest level of quality, while seeking creative innovation. # We are an equal opportunity, affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, age, disability status, gender, sexual orientation, ancestry, protected veteran status, national origin, genetic information or any other legally protected status.


Summary

The System Director of Integrated Medical Group (IMG) Quality is responsible for overseeing the provider practice quality programs across the system. Directs a comprehensive and unified quality program across Covenant provider practices. Responsible for implementing, tracking and monitoring IMG ambulatory quality metrics and recommending quality improvement interventions. Maintains and systematically evaluates the quality and effectiveness of the system-wide program. Facilitates the systematic collection and analysis of quality data to identify trends. Serves as educational resource on quality and regulatory programs providing expert knowledge and guidance. Provides consultation to interdisciplinary team members as needed. Facilitates a continuous state of readiness surrounding accreditation and certification programs.

Essential Duties and Responsibilities

  • Integrates the principles and values of continuous quality improvement (CQI) throughout IMG. Promotes the relevance and use of CQI tools (e.g. process maps, cause and effect diagrams) for ambulatory quality performance and patient experience improvement efforts

  • Monitors and compiles ambulatory quality performance metrics required for regulatory and recognition programs (e.g. MACRA, MU, PCMH), investigates underperformance and offers improvement recommendations.

  • Monitors patient experience survey results and stays current on various quality and patient experience program changes; provides education and training to key stakeholders

  • Ensures that process improvement efforts comply with regulatory and accreditation standards.

  • Advises on accreditation and ISO requirements.

  • Advises on future data and information needs and resources to better support performance and process improvement initiatives.

  • Uses change management processes to engage others in support of the changes required to achieve performance improvement outcomes. Collaborates with practice administration, physician leadership, information services, risk management, care coordination and medical affairs to ensure optimal performance and mitigate issues

  • Assists with audits of medical staff for compliance with policies and procedures and with regulatory and accreditation requirements.

  • Collaborates with CMIO and IT staff to ensure data systems and programs satisfactorily support CQI activities, including maintaining QI tracking systems and database.

  • Participates in significant departmental initiatives. Maintains collaborative team relationships with peers and colleagues.

  • Directly oversees the market IMG Quality Managers.

  • Supports and promotes the mission and values of Covenant Health and the Catholic Health Ministry.

  • Other duties as consistent with this role.

Job Requirements

Education & Experience

  • Bachelor's degree in health care field required; Master's degree preferred.

  • CPHQ certification, or eligible to obtain within 1 year.

  • Minimum of five years of experience in health care setting including three years of management/QI experience performing oversight activities or quality improvement.

Job knowledge and skills

  • Demonstrable commitment to the highest standard of ethical and professional conduct

  • Demonstrates expertise in data management and the use of analytical and statistical tools to identify trends in current processes and systems.

  • Skill in effective application of CQI teams, quality measures, clinical guidelines, and process management initiatives.

  • Skill in consistently meeting reporting requirements of NCQA, HEDIS, CMS, ACO and other regulators and accreditors.

  • Outstanding organizational and project management abilities.

  • Computer skills in Microsoft Office (Word, Excel, Access, PowerPoint and Outlook) for email, scheduling, and navigation of the organization's computer systems. Excellent verbal/written communication and interpersonal skills; skilled in facilitation, presentation and negotiation. Skill in using system software effectively to produce trend analysis, evaluation data, and documentation.

  • Analytical and problem-solving skills and excellent judgment a must

  • Ability to work under pressure and challenging deadlines and adaptability and flexibility required.

Covenant Health Mission Statement

We are a Catholic health ministry, providing healing and care for the whole person, in service to all in our communities.

Our Core Values:

  • Compassion

We show respect, caring and sensitivity towards all, honoring the dignity of each person, especially the poor, vulnerable and suffering.

  • Integrity

We promote justice and ethical behavior, and responsibly steward our human, financial and environmental resources.

  • Collaboration

We work in partnership, dialogue and shared purpose to create healthy communities.

  • Excellence

We deliver all services with the highest level of quality, while seeking creative innovation.

We are an equal opportunity, affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, age, disability status, gender, sexual orientation, ancestry, protected veteran status, national origin, genetic information or any other legally protected status.


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System Director Img Quality

St Mary's Health System