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Exec Direc, Quality %26 Patient

Cape Cod Healthcare

Hyannis, MA
Job Code:
  • Management
  • Information Technology
  • Healthcare
Cape Cod Healthcare
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Job Details

Exec Direc, Quality %26 Patient-180403-50007777
Provides strategic leadership and direction in quality, patient safety, process improvement (PI), outcomes management, and regulatory compliance. Works to establish and promote a culture of safety and operational excellence by working closely with senior leadership and staff to develop, implement and continuously evaluate Cape Cod Healthcare’s (CCHC) approach to quality and patient safety. Builds and fosters relationships and develops and directs the implementation of PI strategies in support of CCHC’s strategic plan and goals. Provides oversight for all quality activities, providing education, support and reports to the Quality Oversight Committee in the areas of Patient Safety, Quality Improvement, Performance Improvement, Patient Satisfaction, Public Reporting of Quality Metrics, and The Joint Commission Survey processes. This position interfaces with all levels of management.
  • Develops, implements and evaluates a comprehensive Quality and Patient Safety Plan that facilitates compliance with regulatory and accreditation compliance and aligns with CCHC’s strategic plan;
  • Serves as a resource and participates in activities and programs related to quality, patient safety, regulatory/accreditation compliance, and process improvement, including, but not limited to, data management (metric definition, data abstraction, aggregation and analysis), identification of opportunities for improvement and process redesign;
  • Proactively educates staff regarding quality improvement methodologies and principles, and quality and patient safety regulatory issues;
  • Regularly communicates quality and patient safety activities to the staff and key stakeholders and engages staff and key stakeholders in quality and patient safety initiatives;
  • Develops quality goals and objectives, including succinct, valid indicators to measure quality processes and outcomes;
  • Establishes a standardized reporting format and a schedule of reporting for quality and patient safety activities to support knowledge-based decision making and to ensure compliance with regulatory and accreditation requirements;
  • Provides direction for planning and organizing regulatory and accreditation survey and follow-up activities within the system, including ensuring sustained compliance with submitted plans of correction;
  • Monitors and reviews regulatory, legislative and accreditation requirement changes and prepares CCHC’s response to changes, following up with appropriate programs to ensure required changes are implemented;
  • Defines priorities and timelines for projects based on an analysis of resource needs and availability;
  • Establishes and maintains collaborative relationships within the affiliates of CCHC and throughout the professional community;
  • Participates in Quality Programs:
    • annual plans and reports
    • peer review
    • safety (FMEAs)
    • performance improvement activities
    • Pay-for-performance programs
    • Joint Commission Continued Readiness
  • In collaboration with finance department, monitors Pay for Performance activities as outlined in reimbursement contracts;
  • Collaborates with legal department to coordinate activities relating to compliance and risk management;
  • Coordinates and attends all Medical Staff Committee meetings and all pertinent CCHC committee meetings where monitoring functions and activities are performed as assigned;
  • Coordinates the process of monitoring, measuring, and assessment of patient care and support of systems to achieve high quality, safe, cost effective Hospital services;
  • Collects and reports HCAHPS data;
  • Facilitates CQI teams and planning sessions as requested;
  • Provides leadership, training and motivation to Quality staff;
  • Establishes operational and fiscal objectives for Quality and ensures the department operates within budget;
  • Measures and reviews performance of direct reports;
  • Performs all duties in accordance with safety guidelines, standards, laws, rules and regulations as set forth by regulatory and governmental agencies and in accordance with established departmental and Hospital policies and procedures.

Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers in a manner that reflects Cape Cod Healthcare’s commitment to CARES: compassion, accountability, respect, excellence and service.

  • RN with current Massachusetts State license required;
  • BSN or related experience;
  • 5 - 7 years of progressive management level experience within QI/PI;
  • Experience in program development, implementation, management, and evaluation;
  • Experience in designing and overseeing quality improvement programs;
  • Experience in compliance with regulatory and accrediting bodies;
  • Superior interpersonal skills (developing and maintaining positive relationships; communicating clearly and effectively with people at all levels; working with others to identify, define, and solve problems);
  • Proven team building skills in dealing with intra-professional clinical and operations teams;
  • Advanced Computer Proficiency, including experience with Microsoft Office products (Word, Excel, Access, Power Point);
  • Demonstrated ability to deliver educational and informational presentations on clinical and/or patient safety topics to a diverse group of stakeholders;
  • Information management skills including flowcharting, data analysis, and report preparation;
  • Ability to inspire others to believe in the culture of patient safety; effective change agent.

Please submit your application and resume directly to:

Scott Mevers
Director, Executive Search
(913) 808-7981

Schedule Details: 
Organization: Cape Cod Hospital
Primary Location: Hyannis
Department: CCH-Quality / Patient Safety
Employee Classification: Regular-Regular
Shift: Day
Weekend Shifts: None
Holiday Shifts: None
Posting Start Date: Apr 3, 2018
Posting End Date: Ongoing
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