Chief Quality Officer - State of Colorado

Chief Quality Officer


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Chief Quality Officer






Salary




$8,637.00 - $13,820.00 Monthly






Location




Denver, CO








Job Type




Full Time






Job Number




IIC 04136 12/9/2024








Department




Colorado Department of Human Services






Division




OBH - CMHIFL








Opening Date




12/10/2024






Closing Date




12/31/2024 11:59 PM Mountain








FLSA




Determined by Position






Type of Announcement




This position is open only to Colorado state residents.








Primary Physical Work Address




3520 W. Oxford Avenue Denver, CO 80236






FLSA Status






Exempt; position is not eligible for overtime compensation.










Department Contact Information




Melissa Baca at melissa.baca@state.co.us






How To Apply




Please submit an online application for this position at https://www.governmentjobs.com/careers/colorado. Reach out to the Department Contact to apply using a paper application, including any supplemental questions. Failure to submit a complete and timely application may result in the rejection of your application. Applicants are responsible for ensuring that application materials are received by the appropriate Human Resources office before the closing date and time listed.











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Department Information






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This position is open ONLY tocurrentColorado State Residents


Most State of Colorado employees are eligible for a great benefit package! Please see the Supplemental Information section below for details! (https://dhr.colorado.gov/state-employees/state-of-colorado-employee-benefits)


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Description of Job



Hospital Wide Management & Supervision of Quality Assurance, Medical Records and Staff Development Departments:

Provides administrative oversight, leadership, and direction to quality assurance, medical records, and staff development strategic department operations. Sets the structure, direction, and ensures quality clinical services for the patients. Follows through on actions required to ensure consistent patient care is delivered and is in compliance with all applicable laws, rules, and regulations. Identifies hospital-wide data needed to analyze functions of the hospital and reviews data regularly to operationalize the findings into plans that expedite improved services for the hospital by maximizing resources available. Develops and presents clear and concise data driven reports that summarize findings for the executive management team and governing body. Is considered an innovator and implements change needed to ensure the quality assurance, medical records, and legal records departmental operations maintain compliance with regulatory agencies; HIPAA, JCAHO, CMS, and CDHS-OCFMH (Colorado Department of Human Service-Office of Civil and Forensic Mental Health) and CMHHIFL policy and procedures. Provides direction to all other executive committee members and works with each department head to ensure hospital-wide compliance with all applicable laws, rules, standards, and regulations. Facilitates the hospital-wide Quality Council and the hospital-wide Quality Safety Oversight Committee.


The Chief Quality Officer (CQO) works with other hospital executives to align the Quality Assurance Performance Improvement Plans strategic initiatives with the hospital's overall vision and the vision of CDHS. This position serves as a key hospital executive leader with the responsibility of day-to-day patient care operations throughout the facility. The CQO participates in short and long-term strategic planning for the hospital and actively promotes the mission of the organization by assuring the achievement of overall quality, service, and performance improvement outcomes. This position supports achievement of balanced scorecard goals for the hospital and assures that the strategies and tactics are aligned with the goals and priorities of the system as a whole and is responsible for tracking the related work stream priorities to achieve such goals. This position identifies gaps and creates solutions and directly manages risks as well as maintains strategy balanced with response to urgent changes.


As a member of the executive committee, this position oversees the policy development for the entire hospital, reviewing, policy drafts, providing guidance and feedback on CMHHIFL policy, providing legislative analysis and feedback as assigned, and making recommendations for internal policy, as well as public policy change in compliance with best practice and all applicable laws, rules, and standards.


The position supervises, manages, and oversees compliance with all hospital operations and service delivery laws, rules, regulatory, and accreditation standards. This position supervises, manages, and oversees approximately 13 staff, either directly or indirectly campus-wide, ensuring provision of services for 138 licensed acute care hospital beds. The direct staff includes: quality assurance specialists, documentation specialists, occurrence reporting and investigations, patient advocacy/patient rights, policy and procedures, medical records, and staff development.


Supervision & Performance Management

Serves as the Appointing Authority for the Quality Assurance, Medical Records, and Staff Development Departments. Responsible for supervision and performance management of Departmental Leaders and their respective subordinates. Determines and sets long-term strategic plans for the Departments to include resource allocation.


Develops hospital wide performance improvement plans and long-term strategic initiatives. This position is actively involved in recruitment and retention of Department personnel, utilizing established procedures, and starting the hiring process, interviews applicants, and recommends hire, promotion, or transfer. Provides oversight of all Department Supervisory Personnel: supervision, timekeeping, progressive discipline (inclusive of issuing Corrective/Disciplinary Actions and conducting Personnel Board Rule 6-10 Meetings), second level signature of performance planning and appraisal (PMP), training and staff competency. Completes corrective and or disciplinary actions. Position has thorough knowledge of State Personnel Board Rules and related CDHS/CMHHIFL policies. Ensures human resources are utilized in optimum fashion with creative and accountable actions by supervisors. Authorizes educational, personal and administrative leave time. Ensures quality service delivery including psychiatric and medical care is delivered. Additional duties of this position include:

1. Chairing of the Quality Council.

2. Ensuring staff adhere to policy.

3. Ensures documentation of regulatory and accreditation requirements is tracked, maintained, and monitored.

4. Responsible for maintaining current licensure without a lapse for any period of time.

5. Ensuring all reportable incidents are done so in a timely manner, all allegations of MANE are thoroughly completed and include appropriate follow-up.

6. Advocating for resources to ensure compliance with all applicable laws, rules, and regulations.

7. Directing department supervisors to evaluate the level of competency and provide specific training to meet these competencies.

8. Provide supervision to enhance job performance.

9. Prepares and maintains any evidentiary documentation for regulatory and/or accrediting agencies in order to maintain hospital licensure.

10. Ensures patient rights


Oversight for all Regulatory, QA/PI and hospital-wide Performance Indicators

and Risk Management:

Represents CMHHIFL during regulatory audits, surveys and during critical incident inquiries, e.g., Colorado Department of Public Health and Environment, CMS, JCAHO, CDHS, etc. Balances regulatory compliance, therapeutic services, and safety and security of patients, staff, hospital, and community. Participates and develops policy and procedures that meets regulatory agency compliance expectations:

Directs policy and training to ensure compliance with regulatory agencies; HIPAA, JCAHO, CMS, and CDHS-OCFMH (Colorado Department of Human Service-Office of Civil and Forensic Mental Health) and CMHHIFL policy and procedures.

Actively participates in RDMS initiatives identified by CDHS-OCFMH, providing accurate information.

Makes recommendations to improve service delivery and mitigate risk to patients and staff.

Directs and addresses performance improvement initiatives through the reporting and analysis of data to demonstrate compliance and improvements in service delivery, or areas of concern and strategies to improve those areas and mitigate risk.

Provide for quality service delivery and standards of practice by the development and implementation of PM/PI and Peer Review activities and departmental liaisons.

Provide for quality service delivery and standards of practice by the development and implementation of PM/PI and Peer Review activities and departmental liaisons.

Reviews patient occurrences and assures the implementation of recommendations and/or strategies to mitigate risk.

Assures participation in hospital-wide QA/PI activities.

Ensures implementation, monitoring, evaluation, and follow-up on all assigned QA/PI activities.

Directs policy and training to ensure compliance with regulatory agencies; HIPAA, JCAHO, CMS, and CDHS-OCFMH (Colorado Department of Human Service-Office of Civil and Forensic Mental Health) and CMHHIFL policy and procedures.

Directs serious and critical events and emergency procedures to ensure adequate interventions are given, proper documentation is completed, and authorities and administrative staff are notified.


Group/Executive Committee Liaison:

Serves as an agent for the State in public forums such as presentations to the Executive Committee and the Department of Human Services. Provides expert opinion regarding the hospital’s quality services and current trends nationwide. Fosters communication within the hospital and ensures proper and timely information is provided to the Executive Committee. Maintains highest public image and professional demeanor when functioning as the CQO. Networks, collaborates, contributes to statewide committees and activities affecting treatment/services to patients.


This position is the liaison to the CEO and Executive Committee and is responsible for participating/leading/reporting on critical committees: Executive Committee, Quality Safety and Oversight Committee, Policy and Procedure Committee, Quality Council, and directs or participates in other committees as assigned.



Minimum Qualifications, Substitutions, Conditions of Employment & Appeal Rights



Experience Only:

Ten (10) years of relevant experience in quality assurance working in a hospital setting or a behavioral health program or closely related field, two (2) of which must have included experience with public or business administration, establishing goals and objectives, as well as developing and managing a budget to achieve program goals and objectives


OR

Education and Experience:

A combination of related education in Nursing, Medical, Social Work, Business, Public Health or closely related field and/or relevant experience in quality assurance working in a hospital setting or a behavioral health program or closely related field equal to ten (10) years, two (2) of which must have included experience with public or business administration, establishing goals and objectives, as well as developing and managing a budget to achieve program goals and objectives.


Preferred Qualifications:



+ Nursing RN License


+ Masters in Degree in Health Care related, Business related, Public Health


+ Experience working in Quality Assurance within a medical or psychiatric hospital setting


+ Experience with Joint Commission, CDPHE, and/or CMS (Centers for Medicare/Medicaid)


+ Experience developing policy and procedure.


+ Demonstrated excellent verbal and written communications skills.



Conditions of Employment

+ Full background check and reference check required

+ Must possess a valid, unrestricted U.S. Driver's License

+ Former State employees who were disciplinarily terminated or resigned in lieu of termination must (1) disclose that information on the application (2) provide an explanation why the prior termination or resignation should not disqualify the applicant from the current position, (3) provide the employee number from the applicant’s 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.





Appeal Rights:


If you receive notice that you have been eliminated from consideration for this position, you may file an appeal with the State Personnel Board or request a review by the State Personnel Director.



An appeal or review must be submitted on the official appeal form, signed by you or your representative. This form must be delivered to the State Personnel Board by email (dpa_state.personnelboard@state.co.us), postmarked in US Mail or hand delivered (1525 Sherman Street, 4th Floor, Denver CO 80203), or faxed (303.866.5038) within ten (10) calendar days from your receipt of notice or acknowledgement of the department’s action.



For more information about the appeals process, the official appeal form, and how to deliver it to the State Personnel Board; go to spb.colorado.gov ; contact the State Personnel Board for assistance at (303) 866-3300; or refer to 4 Colorado Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, at spb.colorado.gov under Rules.





Supplemental Information








How to Apply (https://cdhs.colorado.gov/information-for-job-applicants#how-to-apply)



Need help with your application? Click here.



The Assessment Process (https://cdhs.colorado.gov/information-for-job-applicants#assessment-process)


For additional recruiting questions, please contactmelissa.baca@state.co.us



About Us:


If your goal is to build a career that makes a difference, consider joining the dedicated people of the Colorado Department of Human Services (https://www.colorado.gov/cdhs) (CDHS). Our professionals strive to design and deliver high quality human and health services that improve the safety, independence, and well-being of the people of Colorado. In addition to a great location and rewarding and meaningful work, we offer:

+ Strong, secure, yet flexible retirement benefits including a PERA Defined Benefit Plan or PERA Defined Contribution Plan www.copera.org plus 401(k) and 457 plans

+ Medical and dental health plans

+ Employer supplemented Health Savings Account

+ Paid life insurance

+ Short- and long-term disability coverage

+ 11 paid holidays per year plus vacation and sick leave

+ BenefitHub state employee discount program

+ Employee Wellness program (https://coloradostateofhealth.com/)

+ Excellent work-life programs, such as flexible schedules, training and more

+ Remote work arrangements for eligible positions




*Some positions may qualify for the Public Service Loan Forgiveness Program. For more


information, go to https://www.colorado.gov/pacific/dhr/student-loan-forgiveness-programs .



Our Values:


We believe in a people-first approach: To serve the people of Colorado, we develop a culture and work environment that creates an energized, inspired, and healthy team capable of giving their best to Coloradans .


Balance creates quality of life: We want our team to be resilient through a supportive workplace that values flexibility, health and wellness, and employee engagement.


We hold ourselves accountable: We take responsibility through our actions, programs, and results for the state of health and human services in Colorado.


Transparency matters: We are open and honest with employees, our partners, the Coloradans we serve, and the public.


We are ethical: We abide by what is best for those we serve by doing what is right, not what is easy.


Collaboration helps us rise together: We work together with all partners, employees, and clients to achieve the best outcomes for Coloradans.


We are committed to increasing the diversity of our staff and providing culturally responsive programs and services. Therefore, we encourage responses from people of diverse backgrounds and abilities.


ADA Accommodations: CDHS is committed to the full inclusion of all qualified individuals. As part of this commitment, our agency will assist individuals who have a disability with any reasonable accommodation requests related to employment, including completing the application process, interviewing, completing any pre-employment testing, participating in the employee selection process, and/or to perform essential job functions where the requested accommodation does not impose an undue hardship. If you have a disability and require reasonable accommodation to ensure you have a positive experience applying or interviewing for this position, please direct your inquiries to our ADA Coordinator, Nancy Schmelzer, at cdhs_ada@state.co.us or call 1-800-929-0791.


~THE STATE OF COLORADO IS AN EQUAL OPPORTUNITY EMPLOYER~ (https://cdhs.colorado.gov/information-for-job-applicants#eoe)







Toll Free Applicant Technical Support











The State of Colorado offers permanent employees a variety of benefits including medical, dental, life and disability insurance, as well as a comprehensive leave program. Please click the following link for detailed information: www.colorado.gov/pacific/dhr/benefits


Please note that each agency's contact information is different; therefore, we encourage all applicants to view the full, official job announcement which includes contact information and class title. Select the job you wish to view, then click on the "Print" icon.












01


If you are a current or former State of Colorado employee, please list your employee number (starts with 997...). Failure to provide this requested information may render your application incomplete, and you may no longer be considered for the position.






02


Former State employees who were disciplinarily terminated or resigned in lieu of termination must disclose the information on the application. In the space below, please provide an explanation as to why the prior termination or resignation should NOT disqualify your application from the current position.






03


If you are a former or current state employee, please identify what state agency you work(ed) with and how many years of relevant state service you have related to the position you are applying for. (Ensure this is listed on your application under work experience).






04


The bottom of this job announcement provides links to additional information on how to apply, the assessment process, toll free applicant technical support, and about how the State of Colorado is an equal opportunity employer. Please acknowledge below that you have read the information provided in these links.


+ This information is available to me and I have read this information.


+ I am unable to access the links with this information on the job posting. (If you select this option, please contact the recruiter, whose information is listed on this announcement, so that they can send this information directly to you.)






05


Your legal name is used in the hiring process for background checks. Did you use your full legal name in your application? If not, please update your information before submitting your application.


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06


Describe your experience designing and developing performance measures and facilitating performance improvement teams.






07


Describe your experience analyzing detailed reports and statistical data.






08


Describe your experience implementing regulatory standards and working with licensing entities including the Joint Commission and CDPHE.





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