Job Description

At SCA Health, we believe health care is about people – the patients we serve, the physicians we support and the teammates who push us forward. Behind every successful facility, procedure or innovation is a team of 15,000+ professionals working together, learning from each other and living out the mission, vision and values that define our organization.

As part of Optum, SCA Health is redefining specialty care by developing more accessible, patient-centered practice solutions for a network of more than 370 ambulatory surgical centers, over 400 specialty physician practice clinics and numerous labs and surgical hospitals. Our work spans a broad spectrum of services, all designed to support physicians, health systems and employers in delivering efficient, value-based care to patients without compromising quality or autonomy.

What sets SCA Health apart isn’t just what we do, it’s how we do it . Each decision we make is rooted in seven core values :

• Clinical quality
• Integrity
• Service excellence
• Teamwork
• Accountability
• Continuous improvement
• Inclusion

Our values aren’t empty words – they inform our attitudes, actions and culture. At SCA Health, your work directly impacts patients, physicians and communities. Here, you’ll find opportunities to build your career alongside a team that values your expertise, invests in your success, and shares a common mission to care for patients, serve physicians and improve health care in America.

At SCA Health, we offer a comprehensive benefits package to support your health, well-being, and financial future. Our offerings include medical, dental, and vision coverage, 401k plan with company match, paid time off, life and disability insurance, and more. Click here to learn more about our benefits.

Your ideas should inspire change. If you join our team, they will .

The Quality and Accreditation Manager is a member of the SCA Health Clinical Quality & Patient Safety team and is responsible for developing and implementing organizational initiatives to support accreditation and regulatory continuous readiness, compliance with reporting of required metrics to external agencies and all initiatives to improve quality, patient safety and High Reliability.

• Oversee project prioritization and timeline management of the Accreditation and Regulatory Program include reporting of required metrics and new reporting requirements to external bodies such as CMS, CDC, etc. The initial focus area will be implementation of a program to support reporting of Patient Reported Outcomes Measures (PROMS)
• Practice and demonstrate behaviors associated with the SCA Health Clinical Leader Success Behaviors
• Work in concert with VP Quality & Patient Safety (QPS), QPS and Clinical Informatics and Clinical Operations team to direct, implement, and support strategic clinical-quality initiatives that align with SCA Health goals and objectives
• Support and promote SCA Health mission, vision, goals, and objectives
• Strive to improve the experience of patients, physicians, and teammates across SCA Health, partnering with leadership to incorporate new information and strategies to initiate change if/when desired outcomes are not achieved
• Maintain ongoing knowledge of regulatory, accreditation, and evidenced based practice requirements pertinent to clinical quality, patient safety, and clinical informatics
• Maintain ongoing knowledge and compliance with SCA Health policies and work closely with the QPS leader to recommend, develop, and implement new policies and procedures involving Regulatory Compliance, Clinical Quality and Patient Safety, as applicable

Seek to develop and/or continuously improve self, direct reports, and functional areas:

• Identify appropriate opportunities for providing feedback and evaluation of the effectiveness of the clinical quality, patient safety and regulatory compliance/readiness strategies in place
• Participate in ongoing education to advance knowledge base and professional practice, utilizing new knowledge gained to continually support SCA Health
• Engage in self-evaluation of practice on a regular basis, identifying areas of strength as well as areas for opportunity and implementing actions as applicable
• Provide ongoing professional development support for direct reports, if applicable
• Hold self accountable for high performance and high engagement by articulating goals and expectations, delegating as applicable, monitoring performance, and providing feedback consistently across areas of responsibility
• Mentor colleagues for the advancement of nursing, High Reliability Principles and all efforts to advance improved quality and patient safety

Serve as a liaison among multiple functions to support collaboration in identifying opportunities for improvement and program development and/or support as it relates to regulatory, accreditation and performance improvement:

• Oversees project prioritization and timeline management of the Accreditation and Regulatory Program include reporting of required metrics and new reporting requirements to external bodies such as CMS, CDC, etc.
• Serves as an organizational resource and leader in accreditation and reporting requirements
• Champions and is a role model in all behaviors and strategies that support a culture of High Reliability
• Collaborates with other SCA Health service lanes in the training, education, and instruction of clinical and facility-level users on requirements for public reporting of required metrics and policies/programs pertaining to regulatory compliance, survey readiness and patient safety
• Supports and acts as a leader for continuous readiness efforts and proactively leads the ongoing evaluation, planning and support of the continuous readiness infrastructure and processes to ensure successful accreditation accrediting organizations such as The Joint Commission, AAAHC and CMS
• Identifies regulatory vulnerabilities and determines when significance of vulnerabilities warrant bringing to the attention of VP QPS and other organizational leaders
• Provides guidance on accrediting and certification standards interpretation and other regulatory requirements as they apply to organizational practice
• Develops tool kits, education and reference materials and provides presentations at manager meetings.
• Ensures regulatory resources are up to date, Develops and implements initiatives to evaluate and monitor compliance with regulatory standards through ongoing
• Serves as contact and point person for applicable standards-related manuals, publications and newsletters and educational materials; ensures pertinent information is communicated to appropriate individuals
• Serves as a resource to content experts and executive sponsors in standards and CoP interpretation, insight into upcoming regulatory changes, new requirements, along with partnering to operationalize requirements

• Minimum of five (5) years of relevant work experience in healthcare in supporting healthcare quality and patient safety
• Experience with collaborative work (with IT, Clinical Informatics, etc.) to implement new reporting programs such as new CMS required metrics, new state-specific reporting requirements, CDC/NHSN and reporting to other regulatory agencies
• Proven track record in performance improvement
• Knowledge of patient safety and risk management policies
• Experience establishing, pursuing and monitoring appropriate process and outcome measures for key initiatives using a systems perspective; evaluating the processes by which clinical care and patient services are delivered; identifying areas of opportunity, setting standards for outcomes, developing appropriate systems to monitor outcomes, and overseeing the implementation of process improvements
• Experience working with informatics, metrics, and performance improvement and measurement
• Demonstrated change management skills in a complex healthcare environment
• Experience with tracking, reporting, and improving key quality and safety metrics
• Proficiency in Microsoft (Excel, Word, PowerPoint)
• Excellent written and verbal communication skills

Preferred:

• Ambulatory Surgery Center, Hospital or Surgical Hospital, and/or Perioperative Nursing experience
• Experience implementing and measuring Quality Improvement projects
• Certified Professional in Healthcare Quality
• Knowledge of applicable clinical and technical vocabularies, languages, and taxonomies

Licensure & Certification:

• Current/Ac tive Registered Nurse license, in good standing

Education:

• A bachelor’s degree in nursing (BSN) is required. Master’s Degree in Nursing, Business or similar area preferred.

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