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The University of Miami/UHealth UTower has an exciting opportunity for an Executive Director, UHealth System Quality Management. The Executive Director is responsible for organization-wide oversight and leadership support of process improvement strategies, clinical data quality monitoring and performance improvement initiatives, hospital task force development and support of various committees. Operationalize increased effectiveness of healthcare quality performance improvement strategies to meet established healthcare quality performance, quality assurance, and accreditation requirements and goals for the enterprise, inclusive of Ambulatory Division. She/He is responsible for leading quality management and process improvement optimization for healthcare quality domains within the System. Coach and train staff to identify opportunities for improvement and present actionable data, using various data analytics tools and other data aggregation/analysis methods. Present data in a clear, easily interpreted manner, to make evidence based business decisions that are focused on adding value. Responsible for collaborating with Risk, clinicians, leadership, and other healthcare professionals to recommend and facilitate the implementation of system processes that impact quality performance outcomes for clinical departments, clinical service lines, and interdisciplinary high-performance teams, to meet the highest standards of care and patient safety throughout the continuum. Serves as a representative and or liaison with various hospital committees and departments concerning quality management related matters. Analyze, identify, and apply best practices regarding the use of complex clinical information systems and platforms. Collaborate with implementing and supporting performance improvement systems in a highly collaborative nature. Ensure the operational effectiveness and efficiencies of various data metrics and analytics in order to meet healthcare quality objectives. Responsible for directing daily operations of assigned functions/areas, and strategic direction and oversight.
Remain current on industry trends relevant to the scope of this position, and ensure proficiency in order to lead and verify accuracy of work assignments. Educate faculty, administration and staff in the identification of opportunities for overall quality management improvement. Perform supervisory responsibilities in accordance with the University's policies and applicable law. Responsible for interviewing, hiring, training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing and resolving problems. Responsible for collaborating with university professionals to recommend and facilitate implementation of assigned objectives that impact quality performance for the enterprise and ensure adherence with the vision, mission, and values of the organization. Acts as a role model / resource to all levels of staff. Participate in reviewing and updating the Quality Management Plan, and related policies and procedures. Initiate, establish, and maintain business relationships with key stakeholders, both internal and external to the organization (collaborators, sponsors, and business partners). Recommend methods for improving resource utilization. Manage specific projects and design and maintain reports tailored to specific outcomes and trends. Maintains knowledge of Federal, State, and accreditation regulations, as well as, University policies and practices, in order to ensure quality activities are in compliance with established standards and internal practices. Participate in identifying opportunities, utilizing analytic tools, and data for operational and system effectiveness. Work as a team member to meet departmental goals and state and national reporting goals.
Department Specific Functions
- System Wide Peer Review/Professionalism and Medical Care Review Committee support, System Wide provider Ongoing Professional Practice Evaluations (OPPE)
- System Wide Clinical Quality Initiatives-Zero Harm initiatives and sub-task force (CLABSI/CAUTI, Falls, HAPI, DVT/PE, etc.)
- Hospital Clinical Quality Initiatives-(5 to Thrive)
- Care and Services Committee and associated task force(s). Manages departmental data reports by assisting departments with individual department data analysis and reporting including statistical analysis of data and data mining from various sources
- Clinical Quality Registry- data collection, submission, and outcomes services for Cardiovascular and Thoracic programs: (STS-CABG, STS thoracic, ICD, PCI, TAVR, Mitra Clip, LAAO, Carotid, etc.)
- The Joint Commission (TJC) Primary Stroke Program and ongoing hospital certification. Primary Stroke Clinical Quality Registry data collection and submission. GWTG (Get with The Guidelines)-Services
- Primary Stroke Clinical Quality registry data collection and submission
- Bariatric Center of Excellence: Services: Clinical Quality registry data collection and submission
- Maintain familiarity with provider workflows at UHealth which impact clinical data system optimization
- Accountable for deliverables, which are enterprise-wide in scope, influence, and impact.
- Ensure the establishment of sound processes and optimized process improvement to drive quality care and patient safety, contributing to the attainment of business goals through positive impact on continuous quality improvement outcomes within assigned areas of responsibility, and in collaboration with the Quality Executive Team.
- Direct the supervisory and administrative work in directing and coordinating the personnel resource allocation and use of various data system resources to meet assigned objectives
- Develop mechanisms to abstract data from all UHealth systems to identify opportunities for improvement in data reporting.
- Implements and maintains a written Quality Assurance and Improvement Plan, along with related policies and procedures, consistent with the mission and vision of the organization and in compliance with the Joint Commission and other regulatory agency standards.
- Conducts an annual review of the effectiveness of the Quality management plan and related policies and procedures, and reviews and revises the Plan, its program goals and objectives, and all related policies and procedures as necessary.
- Develops and continuously monitors an internal reporting structure for quality management and related activities.
- Ensures the timely reporting of quality data to appropriate individuals through a systematic and defined multidisciplinary process.
- Assists committees and departments with Pl planning, organization, design of monitoring systems, implementation of study topics and follow-up activity, as necessary. Coordinates timely reporting through the defined, formal reporting structure
- Educates faculty, administration and staff in the identification of opportunities for improvement and methods of collecting, analyzing, and reporting of findings and improvement strategies
- Maintains sufficient knowledge of Joint Commission, Federal and State regulations to ensure hospital compliance with regulations.
- Ensure the identification and monitoring of quality indicators and outcomes, collection and analysis of data, achievement of hospital-wide and department specific objectives of the program.
- Assist the Chair of the Care and Services Committee with conducting monthly committee meetings for all clinical departments. Update the QAPI (Quality Assurance and Performance Improvement) plan yearly, update internal and external performance indicator list for all clinical departments yearly, with approval from leadership, MEC, Board of Directors. Conduct yearly evaluation of the QAPI plan.
This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary. CORE QUALIFICATIONS Education:
- Lead process and performance improvement initiatives for the Quality Department that impact the overall enterprise system, and may work in close collaboration with executives, physicians, management, and other leaders on the opportunities for clinical and/or operational effectiveness.
- Responsible for leading, supervising, and/or collaborating with a team of professionals for successful delivery of identified outcomes, inclusive of implementing and managing processes, procedures, and policies that impact clinical quality improvement, accreditation, quality assurance, and regulatory compliance.
- Ensure critical and valuable information is regularly communicated to leadership and appropriate parties.
- Develop and continuously monitor an internal reporting structure for assigned quality management matters.
- Ensure the timely reporting of quality data to appropriate individuals through a systematic and defined multidisciplinary process.
- Coordinate timely reporting to leadership via a defined, formal reporting structure.
- Responsible for serving as the principle advisor regarding quality process and performance improvement, and obtaining evidence based data for decision-making.
- Analyze, identify, and apply best practices.
Certification and Licensing:
- Master's degree in Healthcare Administration, Business, Finance, Data Analytics, or related field required
- Certified Professional in Healthcare Quality ( CPHQ ) highly desired
- Valid Florida Registered Nurse license
Preference given to any combination of the following experiences:
- Minimum of 7 years' experience in a quality management leadership role, reporting and analysis in a clinical or healthcare environment
- Must have at least 5+ years of management experience
- Must have experience leading teams responsible for healthcare analytics
Knowledge, Skills and Behaviors:
- Coursework, continuing education completion of quality and patient safety, clinical informatics, patient centered outcomes, quality improvement, and related topics
- Experience with EpicCare Ambulatory Core EMR (EpicCare Ambulatory, Care Everywhere, MyUHealth chart, Workbench)
- Previous working experience with any of the following programs preferred: Sequel, ProDiver, Care Discovery, Tableau, NetAccess, Cerner, Sovera and/or Vizio
- Knowledge of the principles and practices of value-based care, including familiarity with barriers to high-value care
- Commitment to University Values: Diversity, Integrity, Responsibility, Excellence, Compassion, Creativity, Teamwork
- Knowledge of business statistics, quantitative methods, performance analysis, and development of business performance dashboards, scorecards and/or KPIs
- Excellent leadership, management, and performance management skills required
- Excellent technical skills: Demonstrated excellence in computer applications, inclusive of the ability to learn new applications and programs; excellent typing skills
- Professionalism: Ability to incorporate national professional organization as well as business unit and health system's goals to improve patient safety and quality outcomes
- Excellent interpersonal and presentation skills: Ability to promote and sustain outstanding interpersonal and customer service skills (verbal and written) while accepting responsibility to ensure all working relationships are respectful and professional
- Ability to collaboratively communicate critical guidelines and requirements to a broad range of clinicians and non-technical staff that obtain the desired results in a collegial manner
- Excellent analytical and problem solving skills, including a thorough understanding of how to interpret business and user needs and translate them into technical requirements
- Ability to work independently with minimal supervision, while successfully managing the prioritization and execution of multiple deadline-driven projects for a team of people and sustaining a high-level of proficiency individually and as a team
- Proven ability to help guide programs and manage employees, with a wide range of skills and experience, at all levels in the company
- Excellent attention to detail: Demonstrated ability to accurately review, screen and enter data
- Excellent communication and presentation skills: Ability to clearly, effectively, and respectfully communicate questions, ideas, and solutions verbally and in writing to a broad spectrum of specialized skill and clinical experience
- Ability to conform to shifting priorities, demands, and timelines through analytical and problem solving capabilities
- Ability to ensure consistent and accurate adherence to established workflows and processes
- Required ability to sustain mature judgement and maintain strict confidential information and patient confidentiality as mandated by HIPAA, and University policies, respect the rights and privacy of others at all times
- Required to maintain current knowledge and practice in compliance with standards established by external regulatory agencies that impact job performance and deliverables, and maintain active licenses / certifications as deemed required by minimum requirements for position, e.g., maintain sufficient knowledge of healthcare quality programs and activities to ensure hospital and medical staff activities are in compliance with regulations
The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more.
UHealth-University of Miami Health System, South Florida's only university-based health system, provides leading-edge patient care powered by the ground breaking research and medical education at the Miller School of Medicine. As an academic medical center, we are proud to serve South Florida, Latin America and the Caribbean. Our physicians represent more than 100 specialties and sub-specialties, and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching, research and patient care. We're the challenge you've been looking for.
Patient safety is a top priority. As a result, during the Influenza ("the flu") season (September through April), the University Of Miami Miller School Of Medicine requires all employees who provide ongoing services to patients, work in a location (all Hospitals and clinics) where patient care is provided, or work in patient care or clinical care areas, to have an annual influenza vaccination. Failure to meet this requirement will result in rescinding or termination of employment.
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