Director Service Line Performance - Cardiovascular

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Summary:

Responsible for programmatic support of the assigned service line including project management and program development, as well as monitoring and facilitation of process changes. Project management may include short or long term assignments to specialty areas within the service line to achieve and maintain certification by an outside body (TJC, IAC, etc.) or internal initiatives. Program development includes direct oversight of operations (patient navigation, scheduling, and follow up) as well as facilitating new advancements in care with physicians, nursing and other care team members. Responsible to analyze research and quality data from internal and external sources and drive process changes to improve patient care and efficiency within the service line. Drives the processes for monitoring performance, reviewing performance as compared to benchmark/goal and developing action plans for accountability and compliance. Assures Compliance and continued readiness for all regulatory agencies. Drives the service line or program specific certification(s) as needed. Serves as the organizational expert for clinical outcomes and expectations for the service line across the continuum of care. Responsible for collaborating with operational leaders, appropriate Medical Directors, Medical Staff Department Chairs/Section Heads and with facility Quality Directors. Provides timely updates on trends, critical issues, and quality issues to the service line leader. Provides input into the annual service line strategic plan development process.

Position Responsibilities:

Responsible for the development and implementation of a project and program plans for the service line that are aligned with the service line strategic plan and has initiatives that have clear objectives, action items, accountability, timeliness and metrics to support plan execution. Involves the appropriate stakeholders in plan development, monitoring and execution.

Researches best practice, evidenced based standards, practice bulletins and national recommendations, regulatory and accreditation requirements and uses this research to support standardization of clinical practice within the service line and across the system. This support may include the development of clinical policies and/or protocols that provide clear guidelines to reduce variation of practices, improve efficiencies, improve patient satisfaction and outcomes. Responsible for working with key stakeholder to educate on policy and practice changes and supporting implementation and monitoring of adherence to practice change as appropriate.

Provides valid and reliable mechanisms for measuring and monitoring volume, throughput and quality metrics that are tracked on service line specific dashboard. Responsible for ensuring in-depth data collection and specific analysis based on areas of concern. Analyzes program data from a variety of sources for reporting on service line goals as well as associated system partners such as for co-management arrangements and other physician contracted services. Facilitates discussions for program improvement action plans.

Leads service line quality team(s). Sets agenda based on the program plan, performance, new findings and accreditation preparation. Drives performance monitoring and accountability. Responsible for escalating and disseminating volume, throughput and quality results as appropriate. Actively participates on various service line committees and/or teams where program specific expertise is needed.

Serves as the organization expert on specific programs within the service line and is prepared to present metrics and initiatives in multiple forums to generate awareness, establish action plans, and assist with process improvement initiatives.

Position Qualifications Required / Experience Required:

Required Experience:

Five years of experience as a professional nurse or equivalent clinical profession, with 3 years recent clinical experience in specialty related area. Must be proficient in Excel, Word, Outlook and PowerPoint with the ability to present data in a variety of ways.

Required Education:

BSN or other clinical BS required, Master's degree preferred.

Training / Certification / Licensures:

Licensure as an RN or other clinician license/certification.

State certification as an APN in specialty strongly preferred

Preferred Qualifications:

• 3 years in a leadership or supervisory role.
• Working knowledge of one or more of the following: STS National Database, ACC/NCDR registries, VQI, or comparable national clinical registries.
• Experience working with Epic and modern BI / visualization tools (Power BI, Tableau, or equivalent).
• Experience managing or overseeing outsourced clinical abstraction vendors.
• Demonstrated ability to engage executive audiences with data and recommendations.
• Active or prior CTSDM, CCDS, or comparable clinical data management certification.
• Direct experience preparing institutions for STS star rating advancement or CMS public reporting positioning.
• Familiarity with cardiovascular clinical workflows across cardiac surgery, interventional cardiology, structural heart, electrophysiology, advanced heart failure, vascular surgery, and thoracic surgery.

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