Director Quality Outcomes - Health Outcomes

Summary:

The Director leads Quality and Regulatory Outcome programs and applications for CHRISTUS Health. Key responsibilities include establishing programs and process standards for supporting system and region stakeholders in meeting national imperatives from agencies both acute and ambulatory, such as CMS (Medicare), National Quality Forum (NQF), National Healthcare Safety Network (NHSN), The Joint Commission (TJC), National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data and Information Set (HEDIS) and more. Utilizes key content expertise for quality reporting and analytic products and programs that support CHRISTUS Health in response to national quality regulatory, reporting, and reimbursement programs, physician profiling, ongoing and focused professional practice evaluation (OPPE/FPPE), and calls for comment. Will develop quality outcome reporting and analytic insights using knowledge and expertise about public reporting, metrics, analytics, and application tools such as Midas+ Care Management, Vizient, Premier, Epic, Meditech, MicroStrategy, and VigiLanz. Working in partnership with the Director of Data Science and Information Systems provides statistically & methodologically sound output, products, and analytics to ensure the system leads and supports quality outcome improvements. Development of this solid quality outcomes foundation will include metric and data validity, including regulatory requirement assessment, hypothesis evaluation, study design/methodology development, and findings in order to drive improvements in clinical, operational, and economic outcomes for CHRISTUS Health. Proactively performs impact analysis of emerging or changing quality program criteria and regulations to continually drive towards our mission of 'Zero Harm' and will have a global view of the organization to bring high-reliability processes and information governance strategies to the performance of job responsibilities. Must be a proactive and decisive person who adapts well to, and initiates changes in quality and regulatory reporting, data governance, analytics, application tools, and program reporting needs. These activities will decrease exposure to risks, increase quality patient care and steward financial and human resources, and perform duties and responsibilities in a manner consistent with CHRISTUS Health Mission, Values, and Service Standards.

Responsibilities:

Public Reporting and Value-Based Imperatives

• Drives value-based initiative integration, reporting, and taskforce needs of CHRISTUS Health, including Joint Commission Standards, CMS Regulations, and State Regulations, in partnership with the System Quality leader to provide consistent processes across the CHRISTUS Health Ministries to include:
  • Leads, directs, and organizes multidisciplinary teams for high reliability and value-based initiative awareness, reporting, and improvement.
  • Foster alignment and engagement across the CHRISTUS Health system and region quality and data leaders.
  • Supports production of reports in collaboration with subject matter experts.
  • Governs and maintains a crosswalk of value-based initiative metrics and requirements (NHSN, NDNQI, CMS: IQR, IPPS, VBP, RRP, HAC, etc.), updates routinely and when regulatory requirements change, and structured communication to key stakeholders.
• Proactively monitors national regulatory initiatives and develops impact analysis for CHRISTUS Health, including close collaboration with Information Management teams to enhance or develop new tools for stakeholders in addressing initiatives.
• Oversees and coordinates the data and profile development processes for regulatory accreditation, including support data for hospital staff for a constant state of readiness, compliance with standards, and promoting a culture of safety.
• Provides system-wide advice on National Imperatives, including pay for performance measures and public reporting of metrics for CHRISTUS Health hospitals and providers to guide necessity, impact for modification, and/or development of process improvement efforts.

Communications

• Serves as internal and external stakeholder point of contact for regulatory-related initiatives and ad hoc analyses to address inquiries & resolve anomalies.
• Communicate to key stakeholders via a comprehensive, standardized format detailing the methods, analysis, and conclusions, and recommended next steps.
• With minimal direction, develops reports to effectively convey regulatory updates from appropriate data sources and systems, including national benchmarks and public ranking data.

Growth

• Demonstrates a commitment to self-improvement as a leader by actively developing the Leadership, Professional, and Technical competencies assigned.
• Has effective development plans for a growing team of associates.
• Continuously evaluates and maintains chosen application tool(s) for alignment with regulations within the CHRISTUS Health System Office, to include:
  • Alignment with value-based imperative metrics
  • Consistency with data governance definitions and processes
  • Collaborates with CHRISTUS Health tool Administrator/stakeholders, as needed for software upgrades and other changes to the tool environment to meet the needs of CHRISTUS Health users
  • Serves as a resource for tool management
  • Modifies or removes inappropriate or inaccurate tool content
• Performs all duties in a manner that protects the confidentiality of patients and does not solicit or disclose any confidential information unless it is necessary in the performance of assigned job duties. Carries out other duties as assigned from time to time by the System Director Health Outcomes & Analytics.

Requirements:

• Master's Degree
• 10+ years of experience managing quality outcomes, large disparate data sets, including CMS data and using quantitative and qualitative analysis to draw meaningful and valid insights, including 5+ years of programming experience using analytic software, such as Excel/SAS/SQL/Python/R.
• Previous experience facilitating teams or leading projects
• Strong communication skills (both oral and written)
• Excellent prioritization, organizational and program management skills
• Must be able to present results to senior leadership and region stakeholders
• Must be a team player and be willing to collaborate and assist with members of the team as necessary.

Work Schedule:

8AM - 5PM Monday-Friday

Work Type:

Full Time