Director of quality Jobs in Pueblo, CO

Job Title

Policy and Procedure Expert

Job Description

This position is open to current Colorado residents only. Please note: This recruitment may be used to fill multiple vacancies. This position is the Policy and Procedure expert, and provides advice for policy development or revision based upon research and analysis of regulatory standards, best practice evidence or other guidance. The position acts as the lead facilitator of the policy and procedure review process, and assigns policies to one of four reference committees prior to approval by the Policy and Procedure committee. This position possesses a comprehensive knowledge of, and effectively applies principals related to the operation of CMHHIP.

Duties in this position include:

• reviews and analyzes current policies, develops more effective implementation strategies for regulatory compliance, and communicates these changes to CMHHIP Leadership
• leads policy related research efforts to match known guidance, and regulatory requirements to formulate policy, and recommends changes
• supports initiatives related to policy that contribute to positive change, and improves patient outcomes. Communicates complex ideas in a manner to increase receiver's understanding
• monitors various source agencies for updates and prepares reports that outline the implications for changes to legislation, rules and regulatory guidance, or other changes that will impact CMHHIP operations
• utilizes knowledge of legal considerations to minimize potential exposure to risk related to policy development and implementation
• provides retrospective analyses related to implemented policy changes to determine effectiveness, and to determine if the desired outcomes have been achieved, and reports findings to CMHHIP leadership
• consults with various stakeholders to promote collaboration, and obtain feedback for proposed policy changes
• participates in various committee meetings as advisor and policy expert
• collaborates with leadership to ensure that position description duties align with policy
• uses knowledge of theories, concepts and principles related to policy along with good judgement to adapt existing guidelines in order to apply them to CMHHIP operational circumstances while ensuring regulatory compliance

Policy Compilation, Tracking, and Dissemination:

• acts as the hospital's coordinator of the Policy and Procedure (P&P) process and the liaison between the P&P Committee, Chief Executive Officer, Executive Committee, Executive Committee of the Medical Staff, Nursing Executive Committee and staff hospital-wide
• ensures all protocols and procedures align with policy
• identifies and designs forms to comply with hospital policy standards and outside agency regulations
• independently monitors and maintains the current policy system for hospital-wide staff to access and assure conformity and current compliance
• plans and develops work processes, maintains electronic systems and procedures to update hospital-wide, department, discipline-specific policies and all interrelated policies and forms to comply with standards of regulatory agencies
• prepares information for hospital-wide dissemination on all policy and medical record form updates and provides technical guidance and direction to enhance education to all staff concerning current policy and procedure
• performs as a collaborative work leader over the policy coordinator, ensuring all policy related work is completed in advance of deadlines

Committee Participation/Leadership:

• organizes, schedules, leads and facilitates all Reference Committee meetings monthly
• independently makes assignments and deadlines to reference committee staff to meet compliance standards for policy
• schedules and facilitates monthly Policy and Procedure Committee meetings after reference committees have reviewed policies assigned to them by this position
• communicates significant policy changes via various media; email, hospital-wide computer based training, or other means, to effectively and efficiently disseminate important policy or procedural information

Other Duties as Assigned:

• maintains updated knowledge of standards: 27-65 Statute, CMS, BHA, JC, and Health Department
• assists in onsite survey activities and/or provides assistance to the Director of QM with completion of the Joint Commission's Focused Standards Assessment (FSA) which is submitted to TJC in non-survey years
• assists with data entry for standards compliance as needed
• perform assigned tasks and duties within the scope of practice for this position

Minimum Qualifications, Substitutions, Conditions of Employment & Appeal Rights

MINIMUM QUALIFICATIONS:

Experience Only: Six (6) years of relevant experience in an occupation related to the work assigned to this position

Or Education and Experience: A combination of related education and/or relevant experience in an occupation related to the work assigned equal to six (6) years

Preferred Qualifications:

• advanced understanding of policy analysis principles and research methods.
• strong written and verbal communication skills.
• ability to organize tasks, manage time effectively, and follow structured processes.
• ability to speak effectively to groups.
• attention to detail, accuracy, and consistency in work output.
• proficiency in standard office software and document management tools.
• education in Public Policy, Public Administration, Political Science, or Government
• relevant years of state service

Conditions of Employment:

• Training, meetings, and other travel may be required
• Continued employment is contingent upon successful completion of the DYS Pre-service Training Academy, Field Training Program (FTO) and mandatory annual training in all subject areas.
• Full Background CBI name check and fingerprint check, ICON Colorado court database, Medicare fraud database, Reference Checks, Professional License verification (licensure requirements), Drug Screen, PREA (Division of Youth Services), Trails check (direct contact with children), CAPS (direct contact with adults Mental Health Institutes, Regional Centers, Veterans Community Living Centers)
• Former State employees who were disciplinarily terminated or resigned in lieu of termination must: Disclose that information on the application. Explain why the prior termination or resignation should not disqualify you from the current position. Provide your employee number from your prior State employment. Absent extraordinary circumstances, prior disciplinary termination or resignation in lieu of termination and failure to provide this information will disqualify the applicant from future State employment with CDHS.
• Shall not initiate or engage in sexual, social, personal or financial relationships with patients either during or any time after hospitalization, even if the patient requests or initiates such a relationship. All relationships with current or former patients must be disclosed on your application
• successfully pass all modules of the CMHHIP New Employee Orientation core curriculum to include English reading comprehension, relevant competency assessments and written/practical exams in Defensive Tactics
• possess the physical ability to successfully complete hospital-adopted physical interventions and CPR; lift arms above head and kick as high as own waist
• stabilize another person to accomplish a controlled take down
• withstand impact on own body using an ASP shield
• rotate body 90 degrees with feet planted for using a defensive tactic
• kneel on one or both knees and stand up again with multiple repetitions
• must be able to see and hear in order to observe, address and respond to potential breaches in safety
• seize, hold, control or subdue violent or assaultive persons and defend oneself or others to prevent injury
• demonstrate body agility, strength of all four limbs and the ability to walk and climb stairs consistently
• work in situations involving assaultive behavior, physical control of another person and/or restraint situations
• ability to read and comprehend the English language; effectively and fluently communicates in English, both verbally and in writing;
• work in an environment with fluctuating noise and temperature (hot and cold) which may include working outdoors in inclement weather and/or concrete floor/wall work settings
• 2-step TB (tuberculosis) screening is required of all new employees upon hire
• annual influenza vaccination, other vaccinations as required by the State and facility.

CDHS Selection Process Explanation:

Employment history is calculated on a full-time basis (40/hrs per week). Part-time employment is calculated on a prorated basis to determine qualifications. Be sure your application specifically addresses your qualifications, experience, work products, and accomplishments as they relate to the position and minimum requirements.

• Preferred Qualifications & Competencies:
• Relevant years of state service experience.