To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values-integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
Facilitate hospitalwide Performance Improvement by supporting departments in their efforts to comply with evidence- based practice standards. Provide a consultative resource for all staff, offering expertise that promotes exceptional quality patient care, services and treatment. Provide interpretive guidance and expertise regarding CMS Conditions of Participation, State of CT Department of Health regulations and The Joint Commission standards for both hospital and hospice programs. Collaborate with representatives of the Yale New Haven Health System in the development of processes and outcomes that positively affects patient care, service and treatment. Facilitate the reduction of process variation through the efficient utilization of time, effort and costs. Analyze data, prepare reports, facilitate groups and provide consultative services related to areas of quality management and patient care. Ability to statistically evaluate and monitor outcomes for analysis and decision- making. Act as a resource with regard to data collection, analysis, reporting and team facilitation in relation to improving clinical care.
Responsibilities: 1. Evaluates and ensures organizational compliance with The Joint Commission and other agencies and recommends change, as indicated. Assures compliance through the monitoring of action plans, concurrent and retrospective studies. 2. Assess Quality assessment activities of all ancillary departments, assisting with the development and creation of a department QA Plan and integration with the hospital-wide continuous quality improvement process. 3. Provides consultation and leadership to members of the clinical staff for the implementation of programs intended to improve the evaluation of practice and improve the quality of services and/or the resolution of clinical issues. 4. Participate in Peer Review process by performing clinical case reviews and supporting departmental and Section Chief Peer Review activities. Analyzes computer assisted studies of patient treatment data, by procedure and outcome to identify clinical practice and resource patterns and trends. 5. Assist with the development, implementation, and monitoring, of the hospital wide Quality Assurance and Performance Improvement Plan. Undertakes special projects related to improving the quality of care, treatment and services provided. Participates in organization safety projects. 6. Participate and/or lead The Joint Commission Continous Readiness activities for Hospital, Home Hospice and off-site areas which includes survey preparation, standards compliance, communication of information to hospital leadership, compliance with Survey Activity Guide, maintaining phone contact lists and session readiness lists. 7. Participate or lead regulatory survey activity visits. Prepare action plans and file reports as needed to regulatory agency.
Master's degree in a healthcare related field or Information Science required
Minimum of three (3) years' experience in Quality Improvement or equivalent, with healthcare related field experience preferred. Experience in Six Sigma / Lean methodology / Project management preferred.
Certified Professional in Healthcare Quality (CPHQ) required
High intellectual demand, requires strong cognitive reasoning and problem solving skills, examination and analysis of data, chart reviews, and creating reports. Strong presentation and communication skills necessary. Knowledge of Microsoft Excel and PowerPoint. Excellent interpersonal skills. An individual who thrives in a team environment but is self directed and can work independently.
Must exhibit excellent inter-personal skills consistent with the hospital's seven standards for exceptional service: Treat the people we serve as guests; Respect the privacy and confidentiality of patients, visitors, and staff; Present a professional image; Answer the telephone professionally; Listen to patients, visitors and staff, then act promptly to address concerns; Anticipate what services and information people need, then take action to provide it; and Maintain a clean and safe environment. Will function as a member of a variety of hospital, medical staff and interdisciplinary committees. Also may represent the hospital at statewide committees as directed by supervisor. Must be able to project manage and meet deadlines. Must be discrete and maintain the highest levels of confidentiality. Must take a collaborative approach to problem solving and when facilitating workgroups, excellent communicator.
Hospital and offsite location travel. Office environment. Regional travel to system affiliates, conferences and association meetings. Walking, throughout the institution, speaking before groups, carrying folders/binders/charts.