Job Description

Employment Status:
Full time
Job Function:
Management and Executive
Department:
327001 Quality Control-Mgmt
Shift Hours / Days:
Monday- Friday, 8:00am - 5:00pm
Hours / Pay Period:
80

We Fight Cancer: Care That Never Quits®

Cancer Treatment Centers of America® (CTCA®) delivers an extraordinary patient experience we call Patient Empowered Care®. We deliver state-of-the-art, high quality care through an integrative model where a team of experts puts patients at the center of their own care. Every day, you will help patients win the fight against cancer. Every day is challenging and rewarding beyond your imagination.

A Culture of Teamwork, Empowerment & Development

CTCA provides Stakeholders with exceptional support and easy access to a wide range of tools and resources they need to bring the best of themselves, every day. Our benefits, wellness, and compensation programs lead the market. We provide extensive training and career development opportunities that encourage professional and personal growth—it is a point of pride. We empower our Stakeholders to deliver the highest standard of care, which we call the Mother Standard®.

Job Summary/Purpose:

Establishes the direction, function and structure for the organization’s quality, patient safety, risk management and accreditation programs. Maintains oversight for the Infection Prevention program.  Works with the Executive Team, Leaders, Medical Staff and other Stakeholders to establish safe and effective practices to ensure high quality of care for patients and to achieve organizational goals and strategic initiatives. 

Job Responsibilities:

  • Create and execute an effective Quality Management/Performance Improvement program:

    • Develop, implement and monitor the CTCA Phoenix Performance Improvement Plan;

    • Complete and annual review of the PI plan and revise the plan as needed to meet organizational goals and regulatory compliance;

    • Develop metrics to drive improvement of care and processes;

    • Oversite of data collection, reporting and submission to regulatory bodies: CMS and TJC;

    • Serves as system administrator for QualityNet or other programs utilized to submit data to regulatory agencies;

    • Collaborates with IT and clinical leaders on Meaningful Use activities;

    • Work with department leaders and the medical staff to identify meaningful metrics to improve processes and care;

    • Serves as the organization’s subject matter expert for quality and performance improvement;

    • Oversees LEAN activities at the organizational level which impact quality, such as Rapid Improvement Events.

    • Provide education throughout CTCA Phoenix on quality management and performance improvement purpose, methods, data collection, analysis and reporting;

    • In collaboration with Administration and Medical Staff leaders, manages the organization’s peer review functions, including OPPE/FPPE;

    • Responsible for the Quality Patient Safety Committee;

    • Participates in all Enterprise-wide Quality Management/Performance Improvement initiatives.

  • Coordinate and execute the Risk Management/Patient Safety program:

    • Develop, implement and monitor the risk management/patient safety plan with annual review and revision to meet organizational goals and regulatory compliance;

    • Oversite for the event reporting system to ensure report capture, tracking, analysis and reporting occurs;

    • Provide education through CTA Phoenix on risk management reduction strategies, patient safety tactics, etc.;

    • Work with the CEO and Enterprise Legal to manage potential and actual litigation events;

    • Serves as the organization’s subject matter expert for risk management and patient safety;

    • Oversees Root Cause Analysis or other activities in response to events;

    • Oversees management of the organization’s Complaint and Grievance process;

    • Collaborate with leaders and the medical staff to respond to Sentinel Events, Medical Disclosures, etc.;

    • Collaborate with Administration regarding reporting of Sentinel Events to appropriate regulatory agencies;

  • Coordinate and execute the Accreditation Readiness program for State, CMS and TJC:

    • Develop, implement and monitor accreditation readiness activities;

    • Implement/change activities to respond to new or revised regulations or standards from the State, CMS or TJC;

    • Lead annual review activities to ensure ongoing compliance with existing regulations and standards;

    • Provide education throughout CTCA Phoenix regarding appropriate accreditation readiness topics to ensure all leaders, medical staff, volunteers, stakeholders, etc. are prepared to respond to on site surveys;

    • Serve as the organization’s Administrator for the TJC website;

    • Serves as coordinator and liaison for on-site State, CMS and TJC surveys.

    • Responsible for collecting, compiling and creating responses to CMS and TJC for on-site survey, complaint investigations, etc.;

    • Leads the organization’s Accreditation Readiness Committee;

    • Participates in all Enterprise-wide Accreditation Readiness initiatives.

  • Has oversight for the organization’s policy and procedure management process including development, revision and annual review of policies and procedures.Participates in Enterprise-wide initiatives involving policies and procedures.

  • Oversees the Infection Prevention Program.

  • Maintains current knowledge and understanding of new or revised regulations, standards or other topics for areas of responsibility.

  • Responsible for leadership of the department:

    • Stakeholders:  position management including interview, hiring/firing, evaluation, coaching, mentoring, training, etc. to maintain an act, engaged workforce
    • Budget:  annual budget recommendations and creation in collaboration with Chief Nursing Officer; management of assigned budget to achieve departmental and organizational goals

Minimum Qualifications:

  • Bachelor of Science in Nursing Degree is required, Master’s in Nursing, Health Care Administration, or related area is preferred.

  • Minimum of three (3) years of recent experience in the same/similar role at a Director level or higher, including management of direct reports is required

  • Experience in applying the Toyota Production System (TPS) in a healthcare or transactional environment is preferred.

  • Registered Nurse in the state of Arizona or be able to obtain licensure prior to employment is required.

  • Certified Professional in Healthcare Quality or Certified Professional Healthcare Risk Management required

  • Certification in Centers for Medicare & Medicaid Services or Joint Commission is preferred

  • LEAN or Six Sigma certification preferred.

The Best Place to Work

We call ourselves Stakeholders because we all have a stake in the care and success of every patient. Today, CTCA Stakeholders deliver healing and hope to patients fighting complex and advanced cancer in Atlanta, GA, Chicago, IL, Philadelphia, PA, Phoenix, AZ and Tulsa, OK.  Each of our hospitals earned a Best Place to Work distinction and receives numerous accreditations that celebrate our culture of clinical quality, innovation, high performance and wellness.

Beyond The Resume, What We Look For

We select people with talent—people who thrive in an environment of continuous improvement. We are creative and resourceful problem solvers. We are inventors and innovators. As a CTCA Stakeholder, you make the difference in the life of a patient.

Do you see yourself working with a passionate team in a dynamic, high growth environment?  Visit www.cancercenter.com/careers  to begin your journey.