Cayuga Health and its affiliates are the region's leading healthcare system and most trusted providers of integrated health services, empowering our people in our mission to equitably improve the well-being of the communities we serve. Our commitment to providing extraordinary healthcare begins with our team of extraordinary professionals who are continuously discovering clinical innovations and enhancing access to the most up-to-date facilities, equipment, technologies, and research protocols. Cayuga Health's commitment to our employees includes competitive compensation, comprehensive employee benefits programs, and the opportunity to explore and build a career in healthcare through our many professional development programs.
This role will be responsible in collaborating with operational leaders across Schuyler Hospital, Seneca View, and Schuyler Hospital's Outpatient Departments to improve external quality measures/programs like PlaneTree designation, Leapfrog Hospital Grade, Critical Access Hospital Top Lists, and other strategic priorities, etc. In order to maintain alignment, this role collaborates with the Director of Quality Outcomes for the Patient Experience & Quality Brand Programs (i.e. - CAH PI Collaborative and work with Stroudwater Associates) and the Manager, Clinical Risk & Regulatory for Patient Relations requirements and standards.
The role will report to the Chief Risk & Quality Officer with a matrix to the Director of Quality Outcomes and PI, and collaboration with the Manager for Clinical Risk and Regulatory for Cayuga Health System. This role will be noted as the Quality lead for Schuyler Hospital and Seneca View.
Roles And Responsibilities
- Quality Leadership| Seneca View:
- Direct the activities of the Quality Assurance & Performance Improvement program to support the Long-term Care/Nursing Home interdisciplinary team in monitoring and embedding of an ongoing person centered and quality improvement culture throughout the nursing home consistent with Cayuga Health System.
- Develops and maintains a knowledge base specific to critical access hospital and long-term care Quality Assurance and Performance Improvement regulatory needs as outlined by CMS and NYS DOH.
- Such items as CASPER Reports, CMS Five-Star Ratings, NHQI, Quality Measures, DOH Survey readiness and risk assessment, NYS DOH plan of corrections associated with NYS DOH health surveys, quality assurance methodologies i.e., Lean Six Sigma and or PDSA and implementation of best practice models i.e., Interact etc.
- Develops Quality Assurance and Performance Improvement (QAPI) standards and implements programs to ensure such standards are met. Develops and maintains documentation/records for the QAPI program, developing, implementing, and maintaining data reporting dashboards that align with facility QAPI program, as directed by the Administrator and/or designee.
- Facilitation:
- Facilitates and chairs (where applicable) committees and workgroups aimed at maintaining compliance and advancing quality within the facility.
- Quality Assurance:
- Develop, implement, and maintain QAPI audit program for the facility. Develop reporting on audit compliance, findings, and identifications for improvement to QAPI Committee.
- Policy Management:
- Responsible for the timely and accurate development of policies and procedures in compliance with governmental, legal and regulatory requirements.
- Incident Reporting Management:
- Responsible for Apparent Cause Analysis (ACA) and Common Cause Analysis (CCA) processes and can lead and/or provide guidance and education as needed. Manages/Assists and/or coordinates debriefing processes as needed.
- Responsible for leading workgroups and investigations to ensure timely follow-up and reporting to internal and external stakeholders (i.e. - Department of Health, etc.).
- Regulation:
- Responsible for ensuring continuous survey readiness in collaboration with operational leaders and the CHS Policy and Regulatory Program Manager.
- Ensures compliance with all regulatory mandates and statutes. To include, but not limited to Joint Commission, NYS Department of Health (Nursing home specific: code 405 & 415), CMS federal regulatory tags, etc.
- Collaborates with Corporate Compliance and Privacy at Cayuga Health to ensure ongoing monitoring and compliance with additional programs.
- Change Management:
- Involves key stakeholders as appropriate to ensure impact and interdependencies with other policies/procedures throughout the Health System are taken into account.
- Ensures that Schuyler Hospital and Seneca View activities are aligned with Cayuga Health level direction and priorities aimed at reducing inadvertent silos.
- Training and Development:
- Identify training needs and opportunities for staff to enhance their understanding and skills associated with risk mitigation, quality assurance/improvement, and process improvement.
- Leverages insights from auditing opportunities to enhance training and education across clinical and non-clinical operational streams.
- Work with the Patient Relations program to ensure that Person Centered principles are engrained in the organization.
Required Skills And Experience
- A Bachelor's degree in Occupational Health and Safety, Environmental Health, Industrial Hygiene, or a related field is required. However, equivalent years of relevant experience can substitute for the educational requirement on a year-for-year basis.
- Minimum of 7 years of experience in healthcare industry with a focus on leadership/management of teams and quality programs.
- Demonstrated experience in chairing safety committees and leading safety initiatives.
- Record of accomplishment in developing and implementing safety policies, auditing plans, and programs.
- Evidences key role in improving clinical outcomes, regulatory performance and transformation in quality assurance, improvement and safety.
- Licensure/Certifications: Certified Professional in Healthcare Quality (CPHQ) required. Must obtain Lean Six Sigma Green Belt certification within 2 years of hire.
- Skills, Knowledge, & Abilities: Excellent relationship management as well as project management skills.
- Strong written and oral communication skills. Critical thinking and creative problem solving.
- Demonstrated ability to manage multiple and sometimes competing priorities.
- Strong analytical skills and experience with data analysis, metrics, and reporting.
- Knowledge of quality assurance and risk management principles.
Preferred Skills And Experience
- Skills, Knowledge, & Abilities: Understanding of healthcare operations, regulatory requirements, and the unique challenges of the healthcare environment is highly beneficial.
Physical Requirements
- This position primarily involves sedentary work. The incumbent will typically perform tasks while seated at a desk or workstation, utilizing computers, phones, and other office equipment. Sedentary work may require occasional standing, walking, or light physical effort, but the majority of duties will be performed in a seated position. Reasonable accommodations may be made to enable individuals with disabilities to perform essential job functions.
- Days/Nights - Flex position - This role will primarily be within traditional operating hours but may change based on project or urgent needs.
Location and Travel Requirements:
- Schuyler Hospital
- Travel to Cayuga Health System (CHS) locations for various meetings, events, and collaborations may be required in accordance with the role's overall responsibilities. This may include periodic attendance at regional Critical Access Hospital quality forums that are facilitated across New York State. The incumbent should be flexible and able to accommodate occasional travel as necessary to effectively fulfill the duties and responsibilities of the role.
Pay Range Disclosure
- $100,000 to $115,000 per year
Cayuga Health System and its affiliates are committed to treating all patients, providers, staff and volunteers equitably and with dignity, ensuring the highest levels of safety, care and respect, and striving to recognize and overcome biases and policies that contribute to disparities in healthcare access, equitable care and positive health outcomes for all.
We are proud to be an Equal Employment Opportunity employer, supporting the growth and health of our employees and community by embracing the rich diversity, needs and circumstances of all peoples and prioritizing opportunities to build a diverse and inclusive workplace. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable protected characteristics.
If you require reasonable accommodation to complete a job application, pre-employment testing, a job interview or to otherwise participate in the hiring process, please contact the Cayuga Health Talent Acquisition team at talentacquisition@cayugahealth.org.
I certify that the information contained in this application is correct and complete to the best of my knowledge. I understand that any falsification or omission of information may disqualify me from further consideration for employment or, if hired, may result in termination. In consideration for my employment, I agree to abide by the rules and regulations of the company, which rules may be changed, withdrawn, added, or interpreted at any time, at the company's sole option and without prior notice to me.
I understand that any hiring decision is contingent upon my successful completion of all of the Company's lawful pre-employment/post-offer checks, which may include a background check, drug screen, employment references, and licensing review. If I am made a conditional offer of employment, I agree to execute any consent forms necessary for the Company to conduct its lawful pre-employment/post-offer checks. Such checks will not be conducted until allowed under applicable federal, state, and local law. I understand if I have a criminal background, it will not automatically disqualify me from employment unless otherwise required by law. I agree to execute any consent forms necessary for the Company to conduct its lawful pre-employment checks.
I also understand that the Company is a drug and alcohol-free workplace and has a drug and alcohol testing program consistent with applicable federal, state, and local law. I understand that after a conditional offer of employment, I must submit to and pass a pre-employment drug test as a condition of employment.
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