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Form of workSenior Manager for Quality and Clinical Compliance
This role is the local administrative leader who oversees the daily activities of Clinical Compliance, quality performance and improvement at Martha's Vineyard Hospital. This role will report directly to the MGB Community Director Quality and Clinical Compliance and is responsible for the performance and execution of the quality and Clinical Compliance programs for Martha's Vineyard. Under the direction of the Community Director for Quality and Clinical Compliance, this role will partner with the MVH ACMO and local clinical teams to implement and execute a robust and comprehensive quality and Clinical Compliance portfolio.
This role will maintain sound organizational relationships and work well within a matrixed health care organization. This role will collaborate with system and site leadership to execute long and short-term goals for the MGB quality and Clinical Compliance programs.
Because this is a local leadership role in an active change management environment, this leader will need to demonstrate flexibility and open mindedness as the contours of this position will actively evolve over time.
Provide essential input to the MGB leadership team for the creation of strategy, policies, infrastructure and performance improvement plans to ensure that MVH delivers the highest quality of care in the nation.
Execute the MGB quality and Clinical Compliance strategy within MVH ensuring adherence to MGB standardized processes around quality measurement, strategy, prioritized areas, and performance improvement while also providing critical feedback about issues and needs that are arising within MVH.
This role is a both a manager of any front-line staff and an implementer of the quality and Clinical Compliance programs at MVH, and is expected to serve a central role in the implementation and execution of both programs.
Serve as the local administrative manager at MVH responsible for performance on all CMS conditions of participation, government and private payer pay for performance activities in the quality and equity domains. Responsible for performance on key MGB priorities within quality. Identify areas at risk and with bidirectional communication and planning with MGB leadership, develop performance improvement planning to ensure we achieve all quality goals at SH.
Responsible for partnering with the MGB data and analytics team to ensure that reporting to CMS and other regulatory bodies (DMH requirements, CMS requirements), private payer contracting, external benchmarking bodies, PSIs, HACs, reportable events etc is timely and correct.
Advise in the creation of any needed MGB or MVH level dashboards around quality performance and improvement that affect MVH.
Specific activities and coordination required:
Liase as needed with MVH Risk/Safety/PFR leader to create prospective solutions and performance improvement as a result of safety events. Partner with safety team as needed prospectively to create performance improvement in pursuit of harm avoidance.
Liase as needed with site infection control team to monitor and improve performance, and respond to data to lower the risk of infections to our patients
Liase with the MVH ACMO as needed to execute system goals and site level improvements.
Provides proactive and reactive quality performance improvement plans, and partner with local teams and department or floor-based teams to improve or implement key improvements as needed.
Leads the planning, implementation and evaluation of process changes or performance improvement activities. Able to effectively and persuasively communicate goals, strategic planning, and accountability processes with clinicians and enlist their partnership for success.
Senior MVH manager responsible for QAPI planning and documentation, and updates as needed for board quality committee/patient care assessment committee.
Supervises activities of Quality staff; oversees recruitment, interviewing, training, and evaluation of quality programs staff. Develops orientation and remediation materials as needed.
Serve as the senior MVH administrative manager covering compliance activities at MVH, ensuring adherence to MVH standardized processes around tracer activity, site level preparedness activities, and measuring/monitoring compliance.
Build out the MGB Clinical Compliance program at MVH, ensuring system-wide, standardized processes, staff training, procedures and governance are in place
Be the local MVH expert for all compliance activities and ensure that MVH either meets or exceeds all of those measures.
Support the MGB Community Director of Quality and Clinical Compliance in developing a system-wide dashboard and/or monitoring program for sites and one that meets MVH's specific needs. Once this is developed, responsible for analyzing trends and emerging risks for MVH, feedback to local teams and to system team
Track institutional compliance with all TJC standards as well as other regulations and advise MGB Community Directorof Quality and Clinical Compliance on areas of improvement.
Under the direction of the MGB Community Director of Quality and Clinical Compliance, provides proactive and reactive Clinical Compliance activities including risk assessments, improvement plans, and partnering with local teams to improve or implement key regulations as needed. Leads the planning, implementation and evaluation of process change at MVH.
Under the direction of the MGB Community Director of Quality and Clinical Compliance, is the senior Clinical Compliance manager responsible for management and performance of all regulatory visits (both expected and unexpected) including but not limited to the Joint Commission, DPH, DMH, and CMS.
Senior Clinical Compliance manager responsible for site preparedness of MVH, ensuring that MVH meets or exceeds all regulatory requirements.
Responsible for overseeing submission of all required documentation and reports to all relevant accrediting and regulatory bodies for MVH (DPH, DMH, TJC, BORIM, MedSUN), and if there are no front-line staff, submit those reports themselves.
Supports State and Federal Office of Rural Health Rural Health activities including generating reports and recommending activities for available grant funds.
Liaise with system and site teams and clinicians as needed for site visits, issues that threaten Clinical Compliance activities, and interpretation of new regulations or requirements.
Prepares reports and presentations as needed
Liases as needed with corporate compliance and office of general counsel in areas where there is key overlap.
Responsible for ensuring that recommended improvements are implemented; partner with ACMO to ensure accountability.
Oversee local training and educational programs as needed
Understand data provided by the system team and use knowledge of local practices and culture to identify areas of opportunity for improvement as well as communicate to the system areas which are at risk.
Provides strong bi-directional communication between the system and the site, with accountability for distribution of organization communication (including pertinent data and analytics) from MGB to SH and vice versa.
Manges the department budget effectively and determines fiscal requirements and prepares budgetary recommendations.
Performs staff performance evaluations establishing a development plan for each employee.
Direct oversight of staff .
Performs other duties as assigned.
EDUCATION REQUIREMENTS:
Undergraduate degree required. A Master's degree in Nursing, Public Health, Business Administration, Public Administration, or Health Services Administration preferred. Clinical background preferred but not required.
Minimum of 5 years experience in quality and Clinical Compliance within a hospital with management experience.
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