Massachusetts Jobs

Hybrid work schedule, Full-time, 40 hours per week

Job Summary:

This role is the local administrative leader who oversees the daily activities of clinical and corporate compliance, quality performance and improvement at Nantucket Cottage Hospital. This role will report directly to the MGB Community Director Quality and Clinical Compliance and is responsible for the performance and execution of the quality and clinical compliance programs for NCH. Under the direction of the Community Director for Quality and Clinical Compliance, this role will partner with the NCH ACMO and local clinical teams to implement and execute a robust and comprehensive quality and clinical compliance portfolio.

This role will maintain sound organizational relationships and work well within a matrixed health care organization. This role will collaborate with system and site leadership to execute long and short-term goals for the MGB quality, clinical and corporate compliance programs. Because this is a local leadership role in an active change management environment, this leader will need to demonstrate flexibility and open mindedness as the contours of this position will actively evolve over time.

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_Essential Job Duties and Responsibilities_

· Provide essential input to the MGB leadership team for the creation of strategy, policies, infrastructure and performance improvement plans to ensure that NCH delivers the highest quality of care in the nation.

· Execute the MGB quality and clinical compliance strategy within NCH, ensuring adherence to MGB standardized processes around quality measurement, strategy, prioritized areas, and performance improvement while also providing critical feedback about issues and needs that are arising within NCH.

· Manager of any front-line staff and an implementer of the quality, clinical and corporate compliance programs at NCH and is expected to serve a central role in the implementation and execution of those programs.

· Serve as the local administrative manager at NCH responsible for performance on all CMS conditions of participation, government and private payer pay for performance activities in the quality and equity domains.

· Responsible for performance on key MGB priorities within quality. Identify areas at risk and with bidirectional communication and planning with MGB leadership, develop performance improvement planning to ensure we achieve all quality goals.

· Responsible for partnering with the MGB data and analytics team to ensure that reporting to CMS and other regulatory bodies (DMH requirements, CMS requirements), private payer contracting, external benchmarking bodies, PSIs, HACs, reportable events etc. is timely and correct.

· Advise in the creation of any needed MGB or NCH level dashboards around quality performance and improvement that affect NCH.

· Specific activities and coordination required:

o Work with NCH Risk/Safety/PFR leader to create prospective solutions and performance improvement as a result of safety events. Partner with safety team as needed prospectively to create performance improvement in pursuit of harm avoidance.

o Work with site infection control team to monitor and improve performance and respond to data to lower the risk of infections to patients.

o Work with the NCH ACMO as needed to execute system goals and site level improvements.

· Provides proactive and reactive quality performance improvement plans, and partner with local teams and department or floor-based teams to implement key improvements as needed.

· Leads the planning, implementation and evaluation of process changes or performance improvement activities. Able to effectively and persuasively communicate goals, strategic planning, and accountability processes with clinicians and enlist their partnership for success.

· Responsible for QAPI planning and documentation, and updates as needed for board quality committee/patient care assessment committee.

· Supervises activities of Quality staff; oversees recruitment, interviewing, training, and evaluation of quality programs staff. Develops orientation and remediation materials as needed.

· Reports out to the Board Quality Committee with the support of the ACMO.

· Serve as the senior NCH administrative manager covering compliance activities at NCH, ensuring adherence to NCH standardized processes around tracer activity, site level preparedness activities, and measuring/monitoring compliance.

· Build out the MGB clinical compliance program at NCH, ensuring system-wide, standardized processes, staff training, procedures and governance are in place

· Be the local NCH expert for all compliance activities and ensure that NCH either meets or exceeds all of those measures.

· Support the MGB Community Director of Quality and Clinical Compliance in developing a system-wide dashboard and/or monitoring program for sites and one that meets NCH’s specific needs. Once this is developed, responsible for analyzing trends and emerging risks for NCH, feedback to local teams and to system team

· Track institutional compliance with all TJC standards as well as other regulations and advise MGB Community Director of Quality and Clinical Compliance on areas of improvement.

· Under the direction of the MGB Community Director of Quality and Clinical Compliance, provides proactive and reactive clinical compliance activities including risk assessments, improvement plans, and partnering with local teams to improve or implement key regulations as needed. Leads the planning, implementation and evaluation of process change at NCH.

· Under the direction of the MGB Community Director of Quality and Clinical Compliance, responsible for management and performance of all regulatory visits (both expected and unexpected) including but not limited to the Joint Commission, DPH, DMH, and CMS.

· Responsible for site preparedness of NCH, ensuring that NCH meets or exceeds all regulatory requirements.

· Responsible for overseeing submission of all required documentation and reports to all relevant accrediting and regulatory bodies for NCH (DPH, DMH, TJC, BORIM, MedSUN, Compliance team), and if there are no front-line staff, submit those reports themselves.

· Support State and Federal Office of Rural Health Rural Health activities including generating reports and recommending activities for available grant funds.

· Liaise with system and site teams and clinicians as needed for site visits, issues that threaten compliance activities, and interpretation of new regulations or requirements.

· Prepares reports and presentations as needed

· Oversee, execute, review and evaluate the Corporate Compliance Program within the organization and has a direct line to the BOT.

· Reports out to the Board Compliance Committee (BCC).

· Responsible for ensuring that recommended improvements are implemented; partner with ACMO to ensure accountability.

· Oversee local training and educational programs as needed

· Understand data provided by the system team and use knowledge of local practices and culture to identify areas of opportunity for improvement as well as communicate to the system areas which are at risk.

· Provide strong bi-directional communication between the system and the site, with accountability for distribution of organization communication (including pertinent data and analytics) from MGB to NCH and vice versa.

· Mange the department budget effectively, determine fiscal requirements and prepare budgetary recommendations.

· Perform staff performance evaluations establishing a development plan for each employee.

· Direct oversight of staff.

· Perform other duties as assigned.

_EssentialKnowledge, Skills, and Experience Required for the Position_

_Knowledge, Skills, and Experience Required_

· Demonstrated knowledge and application of principles of quality measurement, governmental and regulatory quality requirements, process improvement. Demonstrated knowledge and competence in executing and sustaining improvements in clinical care, as well as holding themselves and other stakeholders accountable to sustaining improvement over time. Ability to proficiently explain these domains to others, who may or may not have expertise within rigorous quality improvement.

· Demonstrated ability to successfully lead a local quality performance and improvement team, as well as demonstrated competence and knowledge in clinical care which allows them to partner with departments to achieve key objectives.

· Demonstrated knowledge and application of regulatory bodies, submission of materials, site visits, reviews and accreditations, particularly as it relates to psychiatric care and mental health.

· Demonstrated knowledge of clinical compliance requirements, standards and interpretation.

· Ability to proficiently explain these requirements to others, who may or may not have expertise in compliance. Group facilitation skills; medical staff peer review concepts.

· Demonstrated ability to successfully lead a local site visit from TJC, CMS, DPH, DMH and other bodies as needed.

· Strong background and skill in implementation science, and the ability to move from measuring a problem to correction of the problem with an eye towards sustainability and accountability.

· Ability to balance the need for collaboration vs the need to make executive decisions quickly and reliably.

· Other areas of knowledge include medical records systems; management information systems; applicable statutes and regulatory agency requirements; problem assessment and problem-solving techniques; health care law; health care services.

· Excellent and effective communication skills, both verbal and written, organization, team building and planning skills.

· Competence in statistical analysis; ability to interact with individuals and groups at any level; good decision-making skills; personnel management skills.

· Excellent organizational skills, ability to work on multiple projects under multiple deadlines; highly energetic, and able to embrace challenges and change.

· Must be a team player and work well with a variety of people in all levels of the organization.

· Uphold Behavioral Standards in day-to-day interactions.

· Undergraduate degree required. A Master’s degree in Nursing, Public Health, Business Administration, Public Administration, or Health Services Administration preferred. Clinical background preferred.

· Minimum of 5 years’ experience in quality, clinical and corporate compliance within a hospital with management experience.

_Special Requirements___

· Must be available to assist during regulatory agency reviews.

· Must be available to work in the case of a Hospital declared emergency.

Job: *Professional/Managerial

Organization: *Nantucket Cottage Hospital (NCH)

Title: Senior Manager - Quality, Clinical & Corporate Compliance

Location: MA-Nantucket-NCH Nantucket Cottage Hospital

Requisition ID: 3288330