If you're ready to be part of our legacy of hope and innovation, we encourage you to take the first step and explore our current job openings. Your best is waiting to be discovered.Day - 08 Hour (United States of America)In alignment with the Stanford Health Care Mission Statement “to Care, to Educate and to Discover”, the Stanford Cardiovascular Health Destination Service Line vision is to provide the best care to patients every day by redesigning and transforming cardiovascular care – to prevent, to treat, to cure. The CVH DSL provides care to patients through integration of clinical practice, education, and research. Specialized intra-professional teams of physicians, advanced practice providers (APPs), nurses, pharmacists, social workers, and support staff collaborate to provide coordinated patient care that spans the care continuum. Interdepartmental collaboration with Emergency Department, the cardiac catheterization lab, the operating room, the inpatient units, and outpatient and ambulatory services ensures value-driven and efficient care to patients for optimal outcomes.The Stanford Cardiovascular Health Service line consists of clinical services integrated under a service line model umbrella which includes many specialty and sub-specialty services in Cardiovascular Medicine, Cardiothoracic Surgery and Vascular Surgery. Specialized clinical care includes the Cardiac Arrhythmia Center, Structural Heart Programs of Interventional Cardiology and Transcatheter Aortic Valve Replacement (TAVR), Adult Congenital Heart Disease, Preventive Cardiology, Women’s Heart Health, Marfan’s, Amyloid, Stanford Center for Inherited Diseases, Advanced Heart Failure, heart and lung transplant, multi-organ transplant, Minimally invasive valve and coronary artery bypass graft programs, cardiothoracic surgery program, vascular limb salvage, and the Aortic Center. The inpatient services are supported by physicians and advanced practice providers as well as nurse coordinator navigators and a Phase I inpatient Cardiac Rehabilitation Services team. These teams help assure care coordination and smooth patient transitions from hospital to home. Onsite specialty services include diagnostics (cardiac cath lab, vascular lab, exercise testing, ECG and device clinic, echocardiography, and other imaging modalities) as well as genetic counseling, psychological counseling, and Palliative Care consultation. The Cardiovascular Health Destination Service Line and Network management guidance team governance structure provides a model for alignment with The Stanford University School of Medicine – Division of Cardiology, The Stanford Department of Cardiothoracic Surgery and The Stanford Department of General Surgery – Vascular Surgery.The physician leadership of these departments as well as the executive leadership of the CVH DSL comprise the CVH Executive Council. Physician and operational leadership support the CVH DSL Quality Council, and Operations Councils, in collaboration with the Quality Department and other support departments to provide the structural framework for continuous improvement and innovation implementation. The CVH Quality Council meets monthly to review departmental and registry data and formulate improvement strategies and monitor performance improvement outcomes. The Stanford Cardiovascular Destination Service Line strives for preeminence in precision cardiovascular care through the translation of research to practice by partnering with The Stanford Cardiovascular Institute. Cardiovascular Health DSL strives to develop a value framework for cardiovascular patients through the development of a network of care for access with a focus on quality and safety, cost, and patient experience. Continued expansion of service locations to outlying communities and hospitals in the Stanford system allows the DSL to fulfill the mission of Stanford Health Care and the vision of the Cardiovascular Health Destination Services Line.Essential CVH DSL compliance specific functions:In collaboration with the Executive Director and Medical Director of Cardiovascular Health DSL, the CVH DSL Quality Director will have direct accountability for the preparation, coordination, and facilitation of the CVH DSL Quality CouncilProvides CVH Network support for Cardiovascular Quality Standards complianceResponsible for providing guidance as well as oversight and support for the development, coordination, implementation and evaluation of quality and performance improvement, patient safety, and clinical effectiveness initiatives within the CVH Destination Service Line through facilitation and co-leadership of multidisciplinary teamsCombines the clinical and analytical expertise required to change practice with the leadership skills to influence clinical and operational processes, systems, and outcomesThe Director provides team facilitation, leadership, coaching, change management, and process improvementAdditionally, the Director partners with Operational Directors to ensure the CVH DSL compliance with requirements of external agencies in the area of quality and accreditation surveys/inspectionsEnsures Vizient quality and safety initiatives are routinely reviewed and actions for improvement are identified and acted upon by multi-disciplinary teamsOversees the ongoing medical record reviews, including reviews of documentation required for CMS and TJC, etc.Collaborates with CVH Operational Directors for regulatory and accreditation complianceMaintains current knowledge of requirements related to CMS Conditions of Participation, Joint Comprehensive Cardiac Center Accreditation, STEMI Receiving Center Certification, National Cardiovascular Clinical Practice Guidelines, Guidelines Directed Therapy standards, etc.Oversees and ensures preparation and maintenance of materials/documents used for surveys by CMS/CA Dept of HealthCollaborates with managers and staff to assure continuous readiness for survey with policy and procedure review and revision, mock survey drills, and ongoing education.Develops/revises/implements plans in response to unannounced surveys/visits.Oversees coordination of announced and unannounced visits/surveys.Coordinates preparation of regulatory reports including annual personnel report, changes in key personnel, and reports requested by the Membership and Professional Standards Committee, UNOS.Develops and implements policies that guide and support the provision of services; ensures that policies and procedures are compatible with the function and goals and meet the external regulatory and statutory requirementsEnsures that departments/areas comply with or exceed all regulatory requirements including, but not limited to CMS and TJCParticipates with Director of Quality for Transplant on clinical quality improvement initiatives for Heart and Heart Lung and Multi-organ transplantEnsures compliance for shared Stanford Children’s Health programs: Adult Congenital Heart Program; Stanford Center for Inherited Disease Program through partnerships within Stanford Children’s Health leadershipA Brief OverviewThe Director of Quality provides overall leadership and direction for service line quality and safety across the Destination Service Line (DSL) working under the direction of the Executive Director of the DSL and in a matrixed relationship with the Executive Director of Quality Improvement. Works closely with the Medical Director(s), Vice Presidents, and DSL Executive Director to define quality priorities for the DSL and executes the plan to improve quality and safety. Develops and implements strategic initiatives resulting in clinical outcomes consistent with superior publicly reported and academic comparative quality performance. Ensures alignment between the goals and processes of the organization with DSL including clinics, inpatient units, and all other services that support the program.The leader establishes and implements the strategy and tactics to ensure DSL manages its quality improvement work, using quality improvement methods, measures, information, and data to improve clinical outcomes and satisfy internal and external reporting requirements. This role serves as the DSL's liaison with external reporting agencies regarding overall quality and safety performance.This is an on-site/ hybrid position.What you will do
Develops and implements policies that guide and support the provision of services; ensures that policies and procedures are compatible with the function and goals and meet the external regulatory and statutory requirements.
Ensures that departments/areas comply with or exceed all regulatory requirements and be aware of the current regulatory requirements, including but not limited to The Joint Commission (TJC), California Department of Public health (CDPH), College of American Pathologist (CAP), Occupational Safety and Health Administration (OSHA), Food and Drug Administration (FDA).
Manages the DSL quality staff and provides education and training related to Quality and Safety initiatives, processes, and methodology.
Collaborates with the operational and Department of Quality leaders to ensure all quality goals are met.
Works directly with and supports the medical director(s) of the relevant Service Line outpatient and inpatient clinical units (as applicable), to develop, maintain, and refine measures of clinical quality and safety in support of the clinical, educational, and research mission.
Develops, coordinates, publicizes, and disseminates the quality work results to the DSL administrative and medical leadership. Provides training and support as needed.
Ensures that data regarding Vizient quality and safety initiatives are routinely reviewed and actions for improvement are identified and acted upon by multi-disciplinary teams.
Works closely with the Department of Quality and Safety across the Stanford Medicine ecosystem on cross-cutting initiatives that impact the DSL population throughout their patient care journey, including but not limited to participation in daily huddles, partnerships, and regular interactions with the various teams, including Infection Prevention, Patient Safety, Quality Improvement, Regulatory Affairs, Quality Management, Quality Analytics, Directors of Quality for DSLs and Service lines, and Performance Improvement.
Participates in quality and safety-related committees and initiatives including but not limited to: Management Guidance Teams, Clinical Improvements, Vizient updates, and trainings, as well as the Clinical Documentation and Integrity partnerships.
Review events coming through patient safety reporting system, which captures events causing patient harm, near misses, and lesser levels of potential patient harm, as reported by DSL, SHC, and Stanford School of Medicine personnel.
Ensures the integrity and accuracy of the data utilized to implement process and outcome improvement programs. Works with the SHC quality analytics team and Clinical Business Analytics teams to ensure DSL data needs are met using appropriate data source.
Plans, implements, and evaluates policies, procedures, strategic plans, and new programs related to quality.
Ensures sustainability and scalability of the quality strategies and interventions.
Education Qualifications
Master’s degree in a work-related field/discipline from an accredited college or university is required.
Certified Professional in Healthcare Quality (CPHQ) preferred.
Lean, Six Sigma, or Project Management certifications preferred.
Clinical degree preferred.
Seven to ten plus years of progressive work experience working directly with senior executive leadership. Hospital or outpatient operations experience preferred.
Previous academic medical center transplant quality experience preferred.
Required Knowledge, Skills and Abilities
Demonstration of effective verbal and written communications skills. The successful candidate will produce one or more examples of publication in either the peer reviewed medical literature to which she or he has contributed and been recognized as a co-author or acknowledged as a medical writer, or an example of “enduring materials” in other media. Participation in peer-reviewed publications a plus.
Knowledge of governmental and other regulatory standards, requirements, and guidelines, specifically, Joint Commission, CMS Conditions of Participation, Title 22, California Business & Professions code, California Health and Safety Code, American Society of Clinical Oncology, American College of Surgeons, National Quality Forum.
Knowledge of principles and practices of organization, administration, fiscal and personnel management.
Knowledge of local, state, and federal regulatory requirements related to the functional area.
Knowledge of computer systems and software used in functional area, including Electronic Health Records (EHR). Experience with the EPIC system and its relevant modules (including BEACON) a plus.
Experience with Microsoft Office Products (including Word, Excel, PowerPoint) and Visio.
Demonstrated ability to manage, organize, prioritize, multi-task and adapt to changing priorities.
Ability to provide leadership and influence others.
Ability to foster effective working relationships and build consensus.
Ability to mediate and resolve complex problems and issues.
Physical Demands and Work ConditionsPhysical Demands
Occasional Other. There may be some walking, standing, bending, and carrying of light items such as papers and books. No special physical demands are required to perform the work.
Working Environment
Seldom Other (please list each item under Comments):. Work is performed in a typical office environment with standard equipment and tasks. Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions of the job.
Blood Borne Pathogens
Category III - Tasks that involve NO exposure to blood, body fluids or tissues, and Category I tasks that are not a condition of employment
These principles apply to ALL employees:SHC Commitment to Providing an Exceptional Patient & Family ExperienceStanford 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
#LI-BS1Equal 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.Base Pay Scale: Generally starting at $88.93 - $117.84 per hourThe salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.At Stanford Health Care, we seek to provide patients with the very best in diagnosis and treatment, with outstanding quality, compassion and coordination. With an unmatched track record of scientific discovery, technological innovation and translational medicine, Stanford Medicine physicians are pioneering leading edge therapies today that will change the way health care is delivered tomorrow.As part of our spirit of discovery, we also leverage our deep relationships with luminary Silicon Valley companies to develop new ways to deliver preeminent patient care.Learn about our awards (https://stanfordhealthcare.org/about-us/awards.html) and significant events (https://stanfordhealthcare.org/about-us/our-history.html) .
