<ol> <li> <p>Plans, develops, and directs the Oncology Service Line performance improvement program which efficiently and effectively identifies significant performance improvement opportunities, takes action, provides follow up and communicates these actives to the Oncology Quality Committees.</p> </li><li> <p>Responsible for compliance with all regulatory oncology quality metrics for the service line.</p> </li><li> <p>In collaboration with the Service Line Director and Medical Staff Leadership, develops an annual performance improvement plan that establishes goals and priorities for the department.</p> </li><li> <p>Develops, coordinates, participates, and integrates medical staff and oncology departments' quality improvement activities into the hospital operational goals and strategic plan.</p> </li><li> <p>Ensures adequate support, guidance, and integration of the performance improvement program across the service line for the identification and resolution of opportunities for improvement.</p> </li><li> <p>Identifies patterns or trends, or significant opportunities for improvement program across the service line for the identification and resolution of opportunities for improvement.</p> </li><li> <p>Participates with other departments to establish PI improvement initiatives for the organization.</p> </li><li> <p>Co-Chairs the Oncology Quality Committees every month. Sets agendas and reevaluate value and direction of Committee.</p> </li><li> <p>Works closely with hospital Quality Department Leadership regarding regulatory standards and compliance. Assists in preparing for regulatory body hospital wide survey i.e. Joint Commission, DPH. Commission on Cancer, and NAPBC, ACR. Ensures compliance with all regulatory requirements in regard to practices, policies, and monitoring functions.</p> </li><li> <p>Interprets, educates, and assures department compliance with Oncology specific quality metrics for both radiation and medical oncology.</p> </li><li> <p>Facilitates routine reporting and education for staff and providers on quality and PI metrics established by the Oncology Quality Committees.</p> </li><li> <p>Identifies critical project success factors for tracking, analysis, and reporting including probability and impact of potential risks.</p> </li><li> <p>Responsible for maintaining the components of the cancer-related data collection system consistent with all regulatory and company procedural policies and including management of tumor registry staff.</p> </li><li> <p>Responsible for conducting timely submission of oncology data to all registries and other data initiatives the organization participates in.</p> </li><li> <p>Responsible for maintaining audit and quality assurance process for case findings, abstracting, and coding.</p> </li><li> <p>Responsible for communicating abstracted findings, including potential risks and ideas for improvement in a timely manner to Service Line Director.</p> </li><li> <p>Responsible for abstracting various quality measures from the EHR submission to regulatory and credentialing agencies.</p> </li><li> <p>Conducts periodic walking rounds of all outpatient oncology areas in order to assess effectiveness of implemented systems and encourages staff to provide feedback.</p> </li><li> <p>Recommends computer training for oncology staff, where appropriate. Designs and implements a comprehensive computer training program for department/area staff.</p> </li><li> <p>Works closely with oncology program leadership as new clinical initiatives are explored and implemented to ensure related electronic and manual processes are optimally designed.</p> </li><li> <p>Safeguards the confidentiality, integrity, and availability of patient records and department business data.</p> </li><li> <p>Supports the mission and values of CCH.</p> </li><li> <p>Maintains an in-depth understanding of oncology services and thorough knowledge of the operation of the program including its clinical and administrative workflows, patient flow, quality initiatives, and new clinical programs.</p> </li><li> <p>Develops strategies to ensure all levels of clinical and support staffs are fully engaged with process redesign by maintaining a multidisciplinary approach to all projects.</p> </li><li> <p>Provides department, hospital, and enterprise executive decision makers with oncology services financial, statistical and operational data and analysis, as directed.</p> </li><li> <p>Assigns/delegates project tasks as appropriate.</p> </li><li> <p>Provides project-specific direction and guidance to project team members to facilitate timely and quality results.</p> </li><li> <p>Establishes and maintains a positive project team environment through leadership and mentoring of co-workers and project teams.</p> </li><li> <p>Establishes and maintains effective collaborative work relationships with the oncology department management team, the medical staff, ancillary department managers, CCH leadership, and local technical support staff.</p> </li><li> <p>Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers.</p> </li><li> <p>Challenges current working practices; identifies process improvement opportunities and presents recommendations and solutions to management. Engages and commits to the organization's culture of continuous improvement by actively participating, supporting, and promoting CCHC Pillars of Excellence.</p> </li></ol> <ul> <li>Bachelor's degree in business, nursing, required. Master's degree preferred. </li><li>Five or more years' experience working in Healthcare Quality. </li><li>Solid understanding of federal, local, and oncology specific regulatory standards, program, and quality measurement guidelines in a healthcare setting. Including but not limited to MU, , QOPI, ACoS, NAPBC, ACR </li><li>Exceptional project management skills and substantial exposure to project-based work structures, project lifecycle models, etc. is preferred. </li><li>Experience with formal process improvement methodologies such as TQM, CMM/CMMI, Six Sigma, etc. is preferred. </li><li>Extensive productivity software skills required, including expert level of proficiency in Microsoft Office, Project, and Visio is required. </li><li>Ability to manage project staff, budget, other resources, and timelines and to prioritize and delegate accordingly. </li><li>Ability to conduct research into system issues, standards, and products as required. </li><li>Excellent written and oral communication skills required. </li><li>Strong technical documentation skills are required. </li><li>Knowledge of applicable data privacy laws and practices (i.e. HIPAA, IRB policies) </li><li>Excellent interpersonal skills to effectively interface with department heads, physicians, senior management, vendors, and consultants </li></ul>