Littleton Adventist Hospital is a 231-bed, full-service medical center delivering quality care and Level II emergency care for more than 25 years. Located in the Denver suburb of Littleton, CO, the hospital is surrounded by residential neighborhoods, retail, dining, Littleton’s charming “old town” area, and abundant outdoor space with trails, nature centers and golf courses. In addition to numerous awards for care excellence, we are also leading the way in health care environmental sustainability. Our associates are actively engagedin protecting the health of our environment,working tirelessly to minimize the negativeenvironmental impacts from our operations. Our sustainable achievements have been recognized with several local and national awards, including the Top 25 Environmental Excellence Award from Practice Greenhealth for three consecutive years (2014- 2016). View this shor video to learn why our associates love working here and how our mission and culture help to create fulfilling careers: https://centura-21.wistia.com/medias/e0qve9d10v
Responsible for developing, implementing and evaluating a comprehensive quality program across the continuum of care. Leads a multidisciplinary quality team to impact quality outcomes, patient safety, patient relations, infection prevention and regulatory compliance.
Minimum Education Requirements
Bachelor's degree in healthcare related field
Minimum Experience Requirements
Ten years of experience in a hospital setting
Four years of leadership experience
Experience with risk management and patient safety
Experience in organizational process improvement, change management and/or Lean/Six Sigma
Experience with regulatory readiness and compliance; strong knowledge of the Joint Commission, CMS, and Colorado Department of Health standards
Proven education and facilitation skills; ability to educate and motivate leaders to effectively facilitate improvement projects, process redesign and risk reduction workshops
Strong time management and project management skills
Strong analytical, negotiating and research skills
Strong computer skills
Certified Professional in Healthcare Quality (CPHQ), preferred
Lean/Six Sigma certification, preferred
Position Duties (* denotes an essential functions of the position)
Participates in facility and system-wide quality initiatives and programs.
Maintains expertise in Joint Commission, CMS, Colorado Department of Health and other regulatory standards and surveying methods.
Provides on-site consultation to individual departments to assure that data is being used in quality improvement and risk management initiatives.
Works collaboratively with Care Management to achieve Core Measure Excellence and to improve Quality of Patient Care.
Provides effective oversight of Infection Control program by ensuring analysis, coordination and integration of appropriate infection control measures throughout the facility.
Interprets clinical data and educates departments with comparative data from Centura, CHI and AHS.
Oversees data submission for Joint Commission, CMS and all other regulatory agencies, as well as Leapfrog, AHRQ and other hospital data submission requests.
Serves as resource for quality benchmarks and best practices.
Provides leadership to Quality committee meetings.
Oversees process improvement initiatives for all segments of the Quality program including Regulatory, Patient Safety, Clinical Excellence, Patient Relations and Patient Satisfaction.
Identifies annual learning needs and works with Quality team to devise a learning plan that aligns with quality priorities for the organization.
Facilitates, coaches and consults regarding the best practices and models determined by the Quality Council to be used in carrying out the clinical strategies for the organization. Ensures all quality efforts are in compliance with Joint Commission, CMS and Colorado Department of Health regulations and expectations.
Responsible for the annual quality audit/assessment. Provides recommendations for the medical staff and hospital administration.
Presents recommendations and progress regarding quality improvement to medical staff committees, administration and unit management as needed.
Works closely with other hospital departments to coordinate functions and responsibilities of the Quality Department.
Oversees Patient Safety for hospital including Patient Safety Committee, State Health Department reports and responses, and other hospital specific initiatives.
Oversees improvement initiatives resulting from safety/risk concerns.
Coordinates safety oversight with other departments including environmental safety, biomedical, plant operations, etc.
Ensures regulatory compliance through leading preparation, design and implementations of improvement efforts according to the Joint Commission, CMS and Colorado Department of Health regulations and expectations.
Responds to visits or correspondence from the State of Colorado, the Joint Commission, CMS or any other regulatory agency which relates to quality or regulatory readiness.
May oversee the professional review process and coordinate with Medical Staff office.
Facilitates departmental involvement with multidisciplinary clinical monitoring groups (e.g., Blood Administration, Medication Administration, Resuscitation Monitoring Group, etc.) and ensure regulatory compliance.
Determines qualifications and competence for all supervised associates to include recruitment and selection, preparation of performance evaluations and maintenance of attendance and payroll records.
Provides direction, supervision and support for all supervised associates to maintain their assigned job responsibilities.
Responsible for department budget, including personnel, space allocation and resources necessary to provide designed services.
Develops and directs other procedural and/or special projects related to the Quality Department.
Actively participates in hospital management activities and integrates with department planning.
Important notification to applicants as of Nov. 20, 2014: Effective Jan. 1, 2015, Centura Health will no longer hire tobacco users in Colorado and Kansas. The change to our policy does not apply to associates hired on or before Dec. 31, 2014. Centura Health is an Equal Opportunity Employer, M/F/D/V.
Find your ideal career at Centura Health! With 16 hospitals, physician clinics, hospice services, home care and senior living communities, Centura Health's vast network of care spans Colorado and Western Kansas so you can experience a balanced lifestyle and enjoy a fulfilling career anywhere you want to work, live and play in Colorado. From the fast pace of a Denver-area Level 1 Trauma Center to a... smaller rural or mountain hospital – we proudly offer a more diverse range of work settings and locations than any other health care employer in the state. Centura is an equal opportunity employer.