Senior Quality Consultant - Clinical Lab

Stanford Health Care•Stanford, CA

7h•$71 - $93•Onsite

About The Position

The Senior Quality Consultant is the advanced level of professional work involving the performance of a broad range of performing professional administrative, analytical, and consultative duties related to assessing, planning, implementing, coordinating, monitoring, and evaluating performance improvement and regulatory compliance strategies of Stanford Health Care (SHC) with the goals of maintaining and improving quality of patient care, patient safety, and patient experience while reducing variations and costs of care and ensuring compliance with accreditation, regulatory, and licensing standards, policies, and guidelines applicable to SHC. Initiatives planned and carried out by the Senior Quality Consultant are directed at connecting two critically important priorities for SHC: a) Helping physicians and other health care providers provide the best possible patient care (effectiveness); and b) simultaneously reducing unnecessary and unsustainable costs to the health care system (efficiency). In collaboration with senior leadership, physicians and multi-disciplinary health care providers, the Senior Quality Consultant identifies, conducts and manages complex analytical projects, plans and executes strategies, plans initiatives and methods that provide a comprehensive approach to promoting a strong patient safety culture and clinical effectiveness through effective identification and analysis of safety data and quality indicators, proactive risk assessment, refinement/redesign of systems and processes, interventions, staff training, and patient and family engagement. PERFORMANCE IMPROVEMENT: Leads multiple large scale, organization wide, performance improvement initiatives to improve patient safety and patient care. This role combines the clinical expertise required to change practice with the leadership skills to influence clinical processes, systems, and outcomes. This position will examine effective Models of care delivery for opportunities for optimization and to decrease waste within the systems of care. The Senior Quality Consultant identifies opportunities for organizational wide improvements based on evidence based practices, regulatory and accrediting agency requirements, and data analysis of high risk, high volume and/or problem prone processes. This position is responsible for negotiating timelines and priorities for projects, coordinating action plans, and monitoring/analyzing results for projects that are consistent with the organization's strategic goals and objectives. ACCREDITATION, LICENSING & REGULATORY: Manages compliance with accreditation, regulatory, and licensing standards related to the delivery of safe and effective patient care. The Sr. Quality Consultant AR&L is responsible for facilitating and/or hosting regulatory and accreditation visits such as CDPH, CMS, Joint Commission, or any accreditation and/or regulatory entities. The Sr. Quality Consultant ensures the appropriate staff and managers are involved and that the process is facilitated at all times during the visit. In managing the AR&L functions, the Sr. Quality Consultant will investigate both proposed and new hospital and ambulatory regulations and laws and will make initial recommendations for ensuring compliance. Accreditation and regulatory visit management will encompass accompanying the accreditation or regulatory agents regarding investigations or inspections, advising the Risk and Quality departments of identified issues, and working directly with management and physicians to develop any required action plans for deficiencies. An ongoing mechanism for monitoring action plans and deficiencies and a pro-active process for areas at risk will be established and reported on monthly. This position works collaboratively with the Risk Manager, Quality Patient Safety and Effectiveness staff, staff from the affect department, and senior and middle management as appropriate to investigate significant and sentinel events and to coordinate the root cause analysis process. HIGH-VALUE CARE: The Senior Quality Consultant-HVC supports the Director-HVC and clinical outcome/value improvement teams in developing and implementing a portfolio of methods such as evidence-based medicine, clinical effectiveness, cost effectiveness, pharmacoeconomics, clinical care redesign, pharmacy informatics, and change management. The role directly supports the Stanford Health Care (SHC) strategies for complex care and accountable care across the care continuum.

Requirements

Bachelor’s degree from an accredited college or university in a work-related field, Master’s degree preferred
Eight (8) years of progressively responsible and directly related work experience, five (5) years with a Master’s, within a large acute care hospital or health care system in one or more of the following areas: • Data Based Performance Improvement, including Patient Safety • Quality Assurance/Quality Improvement • Value-Based Care • Regulatory, Accreditation and Licensing • Clinical experience, such as nursing or pharmacy
Knowledge of accreditation, regulatory, licensing and other standards, requirements, and guidelines applicable to hospitals, specifically, Joint Commission, CMS Conditions of Participation, Title 22, California Business & Professions code, California Health and Safety Code, California Medical Association-Institute for Medical Quality, National Committee on Quality Assurance
Knowledge of and ability to apply multiple performance improvement methodologies and tools to projects (e.g. Lean, Six Sigma, FMEA, Poka-Yoke, 5S, SIPOC, value stream mapping, process mapping, cause and effect diagrams, prioritization and selection matrix)
Knowledge of the principles and practices of high-value care, including familiarity with barriers to high-value care
Knowledge of the principles and practices of value-based decision-making, health care payment/reimbursement, and delivery models
Knowledge of the trends, developments, and research in the medical field and with health care systems
Knowledge of the methods, techniques, and procedures used to assess adequacy of patient care provided as well as in recognizing and identifying gaps/deficiencies in services provided
Knowledge of advanced quantitative skills and ability to use statistics to evaluate and interpret data, summarize results and make recommendations
Ability to perform data analysis using statistical process control tools; create & interpret data displays, including clinical, cost, and patient satisfaction data
Knowledge and ability to use decision support systems, Microsoft programs (Access and Excel), Crystal Reports, MIDAS, Business Objects, University Healthcare Consortium (UHC), and other applications & databases management / reporting tools
Knowledge of project management and change management methodologies and tools
Knowledge and ability to use decision support systems such as Access or other relational databases
Ability to utilize the Clinical Effectiveness framework to ensure that performance improvement initiatives focus on improving outcomes, appropriateness of care, patient centeredness, and value
Ability to lead multi-disciplinary teams through Kaizen/RIE/RPIW
Ability to coordinate project initiatives, meetings, and clinical program management to achieve service and unit specific goals and strategic direction
Ability to understand and use structure to drive process changes and how to use processes to drive towards desired outcomes
Ability to define project management processes, tools, and templates as required to drive initiatives
Ability to navigate strategic and operational challenges and achieve objectives with constraints of limited resources and competing demands
Ability to identify potential issues that will impede success, recommend and implement fast corrective action
Ability to effectively analyze and evaluate data or other information to identify, synthesize findings and prepare recommendations into deliverables, and prioritize areas of opportunity
Ability to effectively communicate key messages to diverse groups of audiences to drive the necessary call to action to implement strategies
Ability to stay abreast of inpatient quality measures receiving external visibility and attention (e.g. CMS, HealthGrades, US News & World Report, HEDIS, PQRS)

Responsibilities

Performs data analysis; creates & interprets data displays, including clinical, cost, and patient satisfaction data. Works collaboratively with Information Technology (IT) Informatics team, Finance, Enterprise Data Warehouse/Clinical Business Analytics, and others to ensure the integrity and accuracy of the data that is utilized. Utilizes Microsoft programs, Crystal Reports, MIDAS, Business Objects, University Healthcare Consortium (UHC), and other applications & databases.
Provides expertise in understanding and using SHC data models & systems, and acts as resource in the interpretation and use of data generated and utilized by the department.
Reviews SHC and Quality, Patient Safety, and Effectiveness Department quality goals to identify opportunities for improvement and to ensure current projects are working to meet organizational goals.
Evaluates data, makes judgments, and recommendations regarding quality improvement work, including but not limited to resource utilization, physician practice patterns, and clinical pathway effectiveness. Designs and develops dashboards and other innovative data visualization using business intelligence tools.
Performs, coordinates, and facilitates quality improvement, patient safety activities, and clinical effectiveness initiatives for assigned areas to achieve organization goals, working collaboratively with physicians and staff.
Identifies, designs and implements new processes and clinical care, based on evidence, to continually improve patient care and outcomes and to achieve performance targets.
Provides leadership for creating a culture of patient safety and works with various constituencies to ensure compliance to the National Patient Safety Goals.
Provides expertise in the interpretation, implementation, and maintenance of standards to match external requirements (e.g., Joint Commission, CMS, Title 22)
Provides mentorship to the quality consultants and other SHC leaders and staff.
Identifies the appropriate use of quality improvement tools and methodologies, such as PDCA, Lean, Six Sigma, and Statistical Process Control Analysis on a hospital wide scale.
Leads multidisciplinary and multidepartment strategic quality initiatives.
Provides mentorship and guidance to Quality Consultants.
Maintains network with affiliate institutions, organizations, and associations and other health care providers to stay in touch with developments and trends in the healthcare market as it relates to best practices.
Determines how industry trends and quality improvement pilots / projects impact SHC and consider involvement in them (e.g. Partnership for Patients).
Facilitates local, state, and federal clinical regulatory and accreditation activities for Stanford Hospital and Clinics to ensure that clinical services are provided in accordance with established standards.
Responds to on-site surveyors and regulatory agencies related to patient care matters. Meets surveyor when they arrive on site and coordinates all visit activities.
Notifies appropriate departments that their area may be visited when the regulatory or accreditation surveyors arrive and is responding to a patient care complaint, never-event notification, or survey.
Coordinates with the Risk Manager investigations for reported events and manages the root cause analysis (RCA) process. Establishes processes to ensure that comprehensive reviews of events are timely and that information is sufficient for hospital leadership to make determinations regarding regulatory reporting.
Collaborates with department managers, physicians, and staff to continuously improve operations, increase performance and streamline processes for continuous readiness.
Keeps meticulous records of the visit including documents reviewed, data, minutes, interviews, and other requests for information.
Advises staff, managers, and physicians during the regulatory or accreditation visits on how to respond to surveyors and requests for information.
Coordinates post visit responses to findings and deficiencies to ensure that action plans are in place to bring the organization back into full compliance within the established timeline.
Collaborates regularly with risk management, quality, compliance, and operational managers/directors to continually improve our regulatory accreditation compliance, patient safety, and outcomes of care.
Prepares responses to survey/visit findings, monitors action plans, and reviews results.
Provides regulatory guidance regarding licensure regulations related to clinical professional scope-of-practice and definition of scope of duties for unlicensed personnel; assists in the investigations and fact finding related to clinician professional scope-of-practice and professional licensure matters.
Researches proposed and new regulatory and accreditation requirements related to patient care and translates relevant issues to leadership, existing task forces, quality improvement teams, committees, management and others in the development, revision, and review of policies, processes, and services to ensure ongoing compliance with standards.
Develops and maintains relationships and effective communication with all levels of the medical staff, managers, and staff in order to facilitate problem identification and resolution; models exemplary customer service standards.
Develops and implements the organization’s continuous survey readiness program.
Conduct review and synthesis of current and emerging evidence-based literature relevant to SHC clinical programs and quality initiatives.
Perform analysis of clinical variations and of current state in outcomes and costs of care, and identify key drivers requiring interventions.
Work with clinical teams to develop targeted interventions, including care redesign where appropriate, and to develop implementation plans with metrics and timelines.
Develop standard work, including evidence-based clinical pathways for complex care in collaboration with physician leaders of the clinical programs.
Help translate clinical pathways into Epic order sets and decision support tools in collaboration with nursing, pharmacy and IT teams.
Support the Stanford Value Based Stewardship processes for pharmaceuticals and other high impact clinical resources.
Build relationships with and engage primary care and specialist physicians and residents and provide education when needed in clinical effectiveness methods.
Provide support to the improvement teams focused on reducing 30-day readmissions.
Conduct scholarly work in clinical effectiveness and high value care, and present and publish the findings.