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Director Quality- Stem Cell TransplantJob Ref2400731CategoryLeadershipJob FamilyOncologyDepartmentCellular Therapy AdminScheduleFull-timeFacilityCommunity Howard Regional Hlth3500 South LaFountain StreetKokomo, IN 46902United StatesShiftDay JobHours8:00am-5:00pm Mon-FriBased on business needsJoin CommunityCommunity Health Network was created by our neighbors, for our neighbors. Over 60 years later, “community” is still the heart of our organization. It means providing our neighbors with the best care possible, backed by state-of-the-art technology. It means getting involved in the communities we serve through volunteer opportunities and benefits initiatives. It means ensuring our dedicated caregivers can learn and grow to stay at the top of their fields and to better serve our patients. And above all, it means exceptional care, simply delivered — and we couldn’t do it without you.Make a DifferenceThis position for the Stem Cell Transplant and Cellular Therapy (SCTCT) program is responsible for the program quality oversight. The oversight includes ensuring all components of the program are in compliance with respective regulatory/accreditation agencies, including FDA, CMS, Joint Commission, and FACT. Responsible for coordination and successful execution of all Quality activities which include performance improvement, accreditation and regulatory compliance survey processes and infection prevention programs Performs other responsibilities as required for the effective, safe, or efficient functioning/operation of the department and organization. Collaborates and participates with network leadership and risk management as needed.Exceptional Skills and QualificationsApplicants for this position should be able to collaborate with others in a team setting, have excellent communication skills, and a positive attitude toward problem-solving.
4 year / Bachelor's Degree BSN and Masters prepared or level of knowledge equivalent to that ordinarily acquired through completion of a Master’s degree, preferably in a healthcare related field. OR LCSW with Master's Degree and required certifications/licensures is also acceptable. (Required)
Master's Degree (Preferred).
Certifications/Licensures: Licensed as a Registered Nurse (RN) and/or Licensed Clinical Social Worker (as dictated by healthcare discipline) (Required)
Certified Professional Healthcare in Quality (CPHQ) within three (3) years from hire date. (Required)
5+ years: minimum of three years of progressive quality management administrative experience in a healthcare setting required. May substitute preferred education degree with additional years of equivalent experience on a one-to-one basis. Experience with accreditation and regulatory compliance survey processes preferred. (Required)
Stem Cell Therapy Accountabilities: The position will manage all related documents, including SOPS, emergency plans, sustainable plans, and respective organizational charts. Act as primary liaison for SCTCT systems and ensure ongoing compliance for all regulatory bodies. In collaboration with the senior management team, develop strategic opportunities to improve and optimize the SCTCT informatics systems in alignment with industry good practice, across the scope of the program. This position is responsible for the overall understanding of all clinical procedures performed in the clinical areas including inpatient, outpatient, apheresis, and provider services for patients. Maintain quality recognition and acceptance as an MD Anderson Cancer Center partner within the stem cell, cellular therapy, and transplant arenas. Direct oversight of the SCT Data Management team. Responsible for review and maintenance of the Clinical Quality Management Plan, including moderating a Quarterly Quality Management Program discussion. Perform regular safety checks and safety training to include new staff and refresh senior staff at the Stem Cell Transplant and Cellular Therapy (SCTCT) program. Collaborates with appropriate departments, such as the stem cell processing team, Facilities and Physical Plant. Clinical document management including but not limited to the creation, implementation, revision, and archival of Guidelines of Care, SOPs, Policies, Plans of Care, Treatment Plans, Forms, and Change Control. Perform a wide range of audits throughout the SCTCT quality program to ensure regulatory and accreditation compliance with requirements and standards of practice. Support and training of program staff to maintain consistency, efficiency, and high-quality standards, ensuring regulatory compliance. Works with the IT team to ensure all system validations related to data imports to SCTCT databases are conducted according to regulatory requirements and accreditation standards. Engage in interactions with providers of services for SCTCT, both internal and external to CHNw.
Financial Management: Accountable for financial planning and strategy as well as capital expenditures and budget performance. Establish annual staffing, capital and operating budgets for area of responsibility, assuring that they are executed and support the organization’s overall strategy. Provide effective budget monitoring, financial management, and resource allocation. Seeks and recommends potential opportunities for cost containment and analyzes variances from budget plan or anticipated trends.
Engagement: Models commitment to the mission, vision, values, and objectives of the organization. Creates a sense of energy, excitement, and personal commitment to the organization by empowering others, rewarding and celebrating superior performance, and creating an inclusive culture.
Individuals may not perform all of these duties, or may perform additional, related duties not listed here.
Quality Accountabilities: Responsible for and manages the assigned Quality & Infection Prevention Department activities through the development and implementation of an effective organizational structure, staff supervision, and planning. Facilitates and coordinates performance improvement processes and provides consultative services to assist in achieving regulatory, accreditation, and organizational compliance in quality and performance improvement activities so that regulatory standards are met, and accreditation efforts are coordinated. Takes an active leadership role in accreditation activities to educate and assist with regulatory readiness. Responsible for organizing and submitting action plans and collaborating with the network regulatory director, developing the chapter leaders, and utilizing AMP software tool to analyze performance, prioritize improvements, assess organizational risk and submit reports timely. Establishes specific quality-related goals to measure the organization's processes and outcomes. Provides leadership, back-up and local support to the network infection prevention functions. Develops and oversees the implementation of an effective Organization-wide Quality Management program with the Medical Staff and hospital leadership so that: Clinical and Non-clinical processes, outcomes, and satisfaction are regularly measured and benchmarked, aggregated, analyzed and reported to assigned groups. Conclusions may be drawn, actions taken, follow-up performed, and improvements made and maintained. Reports of the above activities are made to work groups, committees, clinical core groups, Medical Staff Sections, Medical Staff Departments, the Medical Staff Executive Committee, and the Network Board Quality of Care Committee (QoCC) as requested. Promotes and cultivates proactive, rather than reactive, quality efforts by managing variability, ensuring strong process/procedure design and effective process management. Supports the Network focuses on standardization to reduce variation and leads teams that identify root causes of problems rather than focusing on individuals. Acts as a change agent to identify opportunities to improve, resolve problems and evaluate the effectiveness of change and administer programs that focus on improved outcomes of patient care. Coordinates the use of multiple clinical decision support databases available to support value analysis, outcome analysis and change management. Supports the organization’s safety program through an exchange of patient safety, quality and infection prevention information, input into safety education and orientation, as well as providing assistance in investigating situations which pose a possible liability to the organization. Maintains confidentiality of sensitive patient and provider specific information
Why Community?At Community Health Network, we build teams that deliver exceptional care through empathy, communication and collaboration. We consider ALL an integral part of the exceptional patient experience. We PRIIDE ourselves on not having employees but Caregivers. Join our Community as we make a difference in your community.Caring people apply here.Community Health Network complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Community Health Network does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
