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Director of Operations and Quality/Regulatory
2 months ago
Location: Chicago, IL
Hospital: RUSH University Medical Center
Department: General Surgery Transplant MSP
Work Type: Full Time (Total FTE between 0.9 and 1.0)
Shift: Shift 1
Work Schedule: 8 Hr (8:00:00 AM - 5:00:00 PM) * HYBRID WORK OPPORTUNITY*
Summary
The Director of Quality and Operations reports to the Vice President Rush University Medical Group with accountability to Transplant service line administrator. Under the VP/Service line administrator direction, the Director oversees the management of practice operations and the implementation of policies and procedures; b) provides direction to practice administrators, managers, nursing leaders, and performance improvement leadership to ensure safe, welcoming and effective delivery of patient care; sets goals and monitors results to assure that departmental and organizational objectives and operating requirements are met and in line with the goals and mission of the organization; and is responsible for the development, design, operation, and improvement of systems to meet goals and function efficiently and effectively. Exemplifies the Rush mission, vision and values and acts in accordance with Rush policies and procedures.
Other Information
Required Job Qualifications:
Master's degree required.
Seven years progressive health care leadership experience required.
At least two years of people management experience required.
Demonstrated executive leadership capability, relationship development, financial and analytic skills and business acumen.
Strategic planning knowledge and experience.
Preferred Job Qualifications
ASQ certification preferred.
Two or more years of experience in transplantation preferred.
Familiarity with current applicable laws and regulations, including federal, state, and non-federal regulations surrounding organ transplantation strongly preferred (CMS, UNOS, and Joint Commission).
Practice management experience
Experience in an academic medical center.
Responsibilities
Job Responsibilities:
Clinical Operations
Fosters a culture that supports the Rush mission, vision, and values.
Promotes a work environment that encourages staff involvement and input, assists employees to develop and contribute to the organization, and applies human resource policies fairly and consistently.
Leads multidisciplinary teams in the development of policies that advance interdivisional consistency and equity; and which support a coordinated and seamless approach to care delivery.
Provides strategic and operational planning guidance to practice leadership and assures that required infrastructure, staffing, resources, and internal processes are in place to achieve the growth, access, and quality goals of the medical group.
Mentors and coaches practice administrators and managers, oversees their ongoing development, actively works to promote and recognize excellent performance, and identifies potential new leadership talent.
Represents practice interests in the implementation of technology solutions to support the safe, effective, patient centered, and efficient delivery of patient care.
Collaborates with physician and administrative leaders to develop and implement practice service standards that enhance the patient experience and support organizational goals.
Assures RUMG compliance with Rush policies and procedures, conformity to governmental, regulatory, and accreditation guidelines, and achievement of meaningful use requirements.
Achieves Magnet nursing status through implementation of nursing practice standards.
Participates in the design and development of new or expanded services and programs; implements new programs as required.
Operationalizes RUMG strategies, goals, and policies. Defines performance measures, monitors on a regular basis, and communicates results.
Implements strategies around demand/capacity management and referring physician strategies.
Defines staffing models for each practice to support smooth operations, productivity, safe clinical care, appropriate provider support, and the patient friendly provision of services.
Participate in the hiring, evaluation and supervision of the activities of practice administrators and managers of the organization responsible for the day-to-day operations of the medical group physician practices, assuring that organizational goals are achieved at each practice.
Works with the RUMG VP and Department Administrator in preparation and management of budgets, monitoring of monthly financial statements, and takes corrective actions as required.
Responsible for revenue maximization through collection of co-pays, acceptance of participating health plans and proper coding.
Responsible for cost containment through FTE control, supply management and medication inventory.
Resolves problems and champions change.
Quality/Regulatory
Manages Clinical Quality Consultant and Quality Data Coordinator
Develops, implements, and facilitates guidelines, protocols and processes related to transplant program regulatory compliance and QAPI program activities and initiatives.
Identifies, gathers, and trends data and benchmarks to support transplant QAPI initiatives
Completes and coordinates QAPI metric auditing across the transplant programs, and analyzes the data collected against benchmarks and to identify trends in clinical practice that may or may not be in line with projected/desired outcomes.
Assesses clinical documentation to ensure that it is timely, meets standards, and evidences quality of care standards.
Manages development and maintenance of transplant scorecards, and dashboards.
Monitors transplant programs' adherence to regulatory requirements via regular audits.
Coordinates and leads performance improvement projects (including the development of corrective action plans) by use of PDSA (Plan, Do, Study, Act), other Lean methodologies, and other performance improvement tools and interventions.
Works with program staff to develop measurement tools that will track the ongoing maintenance of improvements implemented.
Works with Transplant Program leaders, including the Transplant Nurse Manager, and with administration from other hospital departments, to identify the need for and communicate regarding any new QAPI initiatives, and any new or amended policies and procedures; works with same leaders to ensure education of transplant and other hospital staff regarding any changes/improvements to policies, procedures, or clinical, operational or administrative practice.
Develops, leads and facilitates a readiness program for regulatory surveys
Tracks and ensures that the SOT programs are maintaining regulatory and licensing requirements
Reports on a regular basis to the Transplant Quality Improvement Committee on QAPI program activities, as well as on the results of monthly auditing.
Content expert on CMS, UNOS and Joint Commission regulations, as well as on improvement methodologies, and serves as a resource and provides education as needed to program leaders and their teams.
Develops analytic and measurement strategies for all assigned projects, e.g.- identifying key metrics that will track successful ongoing compliance with regulations and with implemented improvement strategies.
Regularly attends relevant transplant programs' meetings, providing recommendations and professional input as appropriate and identifying best practices that can be shared at monthly Clinical Operations meeting.
Other relevant duties as required.
Rush is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, and other legally protected characteristics.
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