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A Brief Overview The Senior Quality Consultant is the advanced level of professional work involving the performance of a broad range of performing professional administrative, analytical, and consultative duties related to assessing, planning, implementing, coordinating, monitoring, and evaluating performance improvement and regulatory compliance strategies of Stanford Health Care (SHC) with the goals of maintaining and improving quality of patient care, patient safety, and patient experience while reducing variations and costs of care and ensuring compliance with accreditation, regulatory, and licensing standards, policies, and guidelines applicable to SHC.
Initiatives planned and carried out by the Senior Quality Consultant are directed at connecting two critically important priorities for SHC: a) Helping physicians and other health care providers provide the best possible patient care (effectiveness); and b) simultaneously reducing unnecessary and unsustainable costs to the health care system (efficiency).
In collaboration with senior leadership, physicians and multi-disciplinary health care providers, the Senior Quality Consultant identifies, conducts and manages complex analytical projects, plans and executes strategies, plans initiatives and methods that provide a comprehensive approach to promoting a strong patient safety culture and clinical effectiveness through effective identification and analysis of safety data and quality indicators, proactive risk assessment, refinement/redesign of systems and processes, interventions, staff training, and patient and family engagement.
ACCREDITATION, LICENSING & REGULATORY:
Manages compliance with accreditation, regulatory, and licensing standards related to the delivery of safe and effective patient care. The Sr. Quality Consultant AR&L is responsible for facilitating and/or hosting regulatory and accreditation visits such as CDPH, CMS, Joint Commission, or any accreditation and/or regulatory entities. The Sr. Quality Consultant ensures the appropriate staff and managers are involved and that the process is facilitated at all times during the visit. In managing the AR&L functions, the Sr. Quality Consultant will investigate both proposed and new hospital and ambulatory regulations and laws and will make initial recommendations for ensuring compliance. Accreditation and regulatory visit management will encompass accompanying the accreditation or regulatory agents regarding investigations or inspections, advising the Risk and Quality departments of identified issues, and working directly with management and physicians to develop any required action plans for deficiencies. An ongoing mechanism for monitoring action plans and deficiencies and a pro-active process for areas at risk will be established and reported on monthly. This position works collaboratively with the Risk Manager, Quality Patient Safety and Effectiveness staff, staff from the affect department, and senior and middle management as appropriate to investigate significant and sentinel events and to coordinate the root cause analysis process.
What you will do
Accreditation, Licensing & Regulatory
Facilitates local, state, and federal clinical regulatory and accreditation activities for Stanford Hospital and Clinics to ensure that clinical services are provided in accordance with established standards.
Responds to on-site surveyors and regulatory agencies related to patient care matters. Meets surveyor when they arrive on site and coordinates all visit activities.
Notifies appropriate departments that their area may be visited when the regulatory or accreditation surveyors arrive and is responding to a patient care complaint, never-event notification, or survey.
Coordinates with the Risk Manager investigations for reported events and manages the root cause analysis (RCA) process. Establishes processes to ensure that comprehensive reviews of events are timely and that information is sufficient for hospital leadership to make determinations regarding regulatory reporting.
Collaborates with department managers, physicians, and staff to continuously improve operations, increase performance and streamline processes for continuous readiness.
Keeps meticulous records of the visit including documents reviewed, data, minutes, interviews, and other requests for information.
Advises staff, managers, and physicians during the regulatory or accreditation visits on how to respond to surveyors and requests for information.
Coordinates post visit responses to findings and deficiencies to ensure that action plans are in place to bring the organization back into full compliance within the established timeline.
Collaborates regularly with risk management, quality, compliance, and operational managers/directors to continually improve our regulatory accreditation compliance, patient safety, and outcomes of care.
Prepares responses to survey/visit findings, monitors action plans, and reviews results.
Provides regulatory guidance regarding licensure regulations related to clinical professional scope-of-practice and definition of scope of duties for unlicensed personnel; assists in the investigations and fact finding related to clinician professional scope-of-practice and professional licensure matters.
Researches proposed and new regulatory and accreditation requirements related to patient care and translates relevant issues to leadership, existing task forces, quality improvement teams, committees, management and others in the development, revision, and review of policies, processes, and services to ensure ongoing compliance with standards.
Develops and maintains relationships and effective communication with all levels of the medical staff, managers, and staff in order to facilitate problem identification and resolution; models exemplary customer service standards.
Develops and implements the organization’s continuous survey readiness program.
Bachelor’s degree from an accredited college or university in a work-related field, Master’s degree preferred
Eight (8) years of progressively responsible and directly related work experience, five (5) years with a Master’s, within a large acute care hospital or health care system in one or more of the following areas:
• Data Based Performance Improvement, including Patient Safety • Quality Assurance/Quality Improvement • Value-Based Care • Regulatory, Accreditation and Licensing • Clinical experience, such as nursing or pharmacy
Required Knowledge, Skills and Abilities
Knowledge of accreditation, regulatory, licensing and other standards, requirements, and guidelines applicable to hospitals, specifically, Joint Commission, CMS Conditions of Participation, Title 22, California Business & Professions code, California Health and Safety Code, California Medical Association-Institute for Medical Quality, National Committee on Quality Assurance
Knowledge of and ability to apply multiple performance improvement methodologies and tools to projects (e.g. Lean, Six Sigma, FMEA, Poka-Yoke, 5S, SIPOC, value stream mapping, process mapping, cause and effect diagrams, prioritization and selection matrix)
Knowledge of the principles and practices of high-value care, including familiarity with barriers to high-value care
Knowledge of the principles and practices of value-based decision-making, health care payment/reimbursement, and delivery models
Knowledge of the trends, developments, and research in the medical field and with health care systems
Knowledge of the methods, techniques, and procedures used to assess adequacy of patient care provided as well as in recognizing and identifying gaps/deficiencies in services provided
Knowledge of advanced quantitative skills and ability to use statistics to evaluate and interpret data, summarize results and make recommendations
Ability to perform data analysis using statistical process control tools; create & interpret data displays, including clinical, cost, and patient satisfaction data
Knowledge and ability to use decision support systems, Microsoft programs (Access and Excel), Crystal Reports, MIDAS, Business Objects, University Healthcare Consortium (UHC), and other applications & databases management / reporting tools
Knowledge of project management and change management methodologies and tools
Knowledge and ability to use decision support systems such as Access or other relational databases
Ability to utilize the Clinical Effectiveness framework to ensure that performance improvement initiatives focus on improving outcomes, appropriateness of care, patient centeredness, and value
Ability to lead multi-disciplinary teams through Kaizen/RIE/RPIW
Ability to coordinate project initiatives, meetings, and clinical program management to achieve service and unit specific goals and strategic direction
Ability to understand and use structure to drive process changes and how to use processes to drive towards desired outcomes
Ability to define project management processes, tools, and templates as required to drive initiatives
Ability to navigate strategic and operational challenges and achieve objectives with constraints of limited resources and competing demands
Ability to identify potential issues that will impede success, recommend and implement fast corrective action
Ability to effectively analyze and evaluate data or other information to identify, synthesize findings and prepare recommendations into deliverables, and prioritize areas of opportunity
Ability to effectively communicate key messages to diverse groups of audiences to drive the necessary call to action to implement strategies
Ability to stay abreast of inpatient quality measures receiving external visibility and attention (e.g. CMS, HealthGrades, US News & World Report, HEDIS, PQRS)
These principles apply to ALL employees:
SHC Commitment to Providing an Exceptional Patient & Family Experience
Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford’s patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery.
You will do this by executing against our three experience pillars, from the patient and family’s perspective:
Know Me: Anticipate my needs and status to deliver effective care
Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health
Coordinate for Me: Own the complexity of my care through coordination
Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.
Stanford Health Care, with multiple facilities throughout the Bay Area, is internationally renowned for leading edge and coordinated care in cancer care, neurosciences, cardiovascular medicine, surgery, organ transplant, medicine specialties, and primary care. Throughout its history, Stanford has been at the forefront of discovery and innovation, as researchers and clinicians work together to improve health, alleviate suffering, and translate medical breakthroughs into better ways to deliver patient care. Stanford Health Care: Healing humanity through science and compassion, one patient at a time.
At Stanford Health Care, your career is supported within a distinctive hospital culture. This environment compliments the pioneering, collaborative atmosphere that has earned us our worldwide reputation for excellence.