Description:

ESSENTIAL FUNCTIONS

Knows, understands, incorporates,anddemonstratestheMercyOne (TrinityHealth)Mission,Vision,CoreValues, Actions and Promise inbehaviors,practices,anddecisions.

Assiststhe manager in areas of oversight ofquality,patient safety(inclusive of theculture of safety (TogetherSafe)work) and infection prevention across the ministry.

Supports the workofqualityand safety related to the qualityassurance and performance improvement plan, local/region/system strategies, regulatoryand accreditingbodyrequirements (i.e., Centers for Medicare and Medicaid Services (CMS),IowaDepartment of Inspections and Appeals (IDIA),The Joint Commission (TJC),etc.),in conjunction with thehospital’sleaders, colleagues and providers.

Identifiesproblem areas in need of focused attentionand supports the manager toimplement actions to drive improved outcomes.

Assiststhe managerin achievingthe best outcomes aligned to CMS,pay for performance programs(including those aligned to commercial carriers) and TJCin areas of quality measures and regulatory requirements.

Promotescontinuousimprovementtoward achievingexcellentoutcomes and recognitioninregards tooutside “rating” organizations,including(not all inclusive)CMS, Leapfrog, Healthgrades,and BlueDistinctionetc.

Collaborates withMedical Groupexecutive leadership,providers,and leaders in meeting/exceeding standards of excellence and achieving national designations, certifications, and awards.

Collaborates withcolleagues in areas ofaccreditation,risk management,patient experience,clinicalpracticeandperformance excellence to provide identified and needed support for improvement.

Serves as a resource for Clinic Operations and Clinical Leaders in the development, implementation, and evaluation of patient care programs and clinic practice standards, including policies, guidelines,proceduresand professional practice models.

Facilitates and supports the local market Medical Practice Committees.

Assistswith implementation of quality excellence systems that integrate LEAN and other methodologies asappropriate tocreate a data-driven quality improvement programming.

Providesappropriate support, and/or consultative services (project design,selectionof datarequired, development of documentation tools, etc.) to quality improvement teams.

Works closely withcolleaguesin improvingthe organization's culture of safety - including the concept of a “Just Culture” and “TogetherSafe”.

Supports opportunities for improvement on Cause Analyses (apparentcause, root cause, common cause),Healthcare Failure Modes and Effects Analysis (HFMEA), and Patient Safety Organization (PSO) initiatives.

Assiststhe manager inensuringaccuracy ofdata inregulatory and accreditingquality databases (i.e., CMS HARP, TJC), registries,anddashboards/scorecardsfor internal and external customers.

Promotes an environment of sharedleadership,decision-makingand accountability.

MaintainsaworkingknowledgeofapplicableFederal,State,andlocal lawsandregulations,TrinityHealth'sOrganizational Integrity Program, Standards of Conduct, as well as otherpoliciesand proceduresin order toensure adherenceina manner that reflects honest, ethical,andprofessionalbehavior.

Supports organizational evidence-based practice,innovationand research.

Assiststhe managerin the clinical contracting process, consistent with legal and regulatory requirements.

Contributes to the quality process in evaluatingproviderperformance,inclusive ofthe focused and ongoing professional practice evaluation review process.

Maintain awareness of and respond to issues in areas including the following:

• Ethnic, cultural and diversity changes in the population

• Political and social influences

• Financial and economic issues

• The aging of society

• Ethical issues related to healthcare

Perform other duties consistent withthepurpose ofthejob as directed.