Who we Are:Nestled in the most northern part of Vermont, North Country Hospital (NCH) is a community-focused 25 bed critical access hospital, where we prioritize the well-being of our neighbors. North Country Hospital is more than just a healthcare provider; we are a vital part of the community, working together to build a healthier future. Our patient’s health is our priority, and we go above and beyond to care in every way possible.Position Statement:The Manager of Healthcare Quality facilitates and coordinates North Country Hospital’s system wide Quality Assurance and Performance Improvement Program to ensure high-quality healthcare services. This position oversees the implementation and maintenance of quality improvement strategies and ensures compliance with CMS Conditions of Participation.Key Responsibilities:Working closely with the Senior Director of Healthcare Quality, coordinates the work of the Quality Improvement Committee (QIC ith Quality Improvement Coordinators, NCH’s Leadership, Directors and other staff, assists in the development, monitoring and implementation of measurable goals and objectives to provide meaningful reports to the QIC.Facilitates and coordinates the hospital’s system-wide Quality Assurance/Performance Improvement (QA/PI) Program to ensure compliance with CMS Condition of Participation and accreditation standards. This includes:
Oversee monitoring and implementing indicators (clinical and patient safety measures, patient experience, Electronic Clinical Quality Measures (eCQMs) and Merit- Based Incentive Payment System (MIPS), etc. to meet best practice benchmarks and position NCH to respond to external customers/mandates from various sources (CMS, State of Vermont, QIO and other payers/interested parties. This includes routine reviews of clinical informatics data and performing chart reviews. Provide and/or assist responsible parties in providing public reporting of NCH clinical data.
In collaboration with the Senior Director of Healthcare Quality, coordinate the annual review of NCH’s Quality Program with revisions as recommended by QIC and administers NCH’s Quality Program to meet organizational goals.
Collaboratively cultivate accountability for clinical quality, patient safety and patient satisfaction at every level of the organization by providing overall support, positive solution-focused direction and guidance to departments and medical staff to evaluate clinical and patient safety performance.
In collaboration with the Physician Chairperson, coordinates of NCH’s Medical Staff Quality Assurance (MSQA) Committee, including preparation of meeting agendas, communication in between meetings, data to be reported and meeting minutes.Assists in system-wide risk identification and resolution of risk concerns, including reviewing, investigating, and initiating improvement activities for clinical events reported through NCH’s incident reporting system, in partnership with NCH’s Leadership, Directors and other staff.Participates in the Patient Safety Program and Hospital Safety Committee, reporting on a variety of patient and organizational safety measures. Reports patient safety and quality measures to external agencies as required.co-manages platform NCH’s patient experience and patient complaint and grievance processes and works with NCH Leadership and Directors to:
identify organizational-wide and department/service specific patient experience goals and monitor progress in achieving them.
address patient complaints and grievances in a timely and effective manner and in accordance with policy requirements.
identify and address problems/complaints that arise, investigate and direct inquiries and complaints to appropriate hospital staff and act as an intermediary to hospital administration and/or medical staff on behalf of patients and their families.
collect data and provide information about patient care problems to appropriate hospital staff members and/or Committees.
Working closely with the Senior Director of Healthcare and Quality and Quality Management Coordinators, assists in ensuring NCH’s compliance with CMS Conditions of Participation and DNV and other accreditation standards, including survey readiness activities and response should non-conformities be identified. This may include policy and procedure development, process improvement initiatives and other activities.Supervises the Employee Health Nurse and the Infection Preventionist, ensuring coverage for their duties if needed. Includes routinely meeting with each staff person to set mutually agreed upon priorities, monitor progress toward meeting those priorities and serve as a resource should barriers develop.Knowledge, Skills and Abilities:
RN with current Vermont RN license with relevant bachelor’s degree and strong clinical skills.
Three recent years of hospital or healthcare quality experience, including staff supervision
CPHQ preferred, expected within three years of hire
Collaborative problem-solving skills with a variety of stakeholders, including clinical, non-clinical hospital staff, Leadership, Medical staff and patient and families.
Abilities to lead by example, be action-orientated and enjoy taking on new challenges.
Able to make decisions in a timely manner, work well under pressure and meet multiple competing deadlines.