Job Details
Job Location
CBO Office - Atlanta, GA
Position Type
Full Time
Education Level
High School or GED
Travel Percentage
As needed for business requirements.
Job Category
Endoscopy
Description
GENERAL SUMMARY OF DUTIES: The United Digestive Endoscopy Operations Manager is responsible for developing and implementing organizational initiatives to support continuous readiness for maintaining accreditation and meeting regulatory standards. This includes interpreting standards, ensuring compliance, educating staff, and managing survey operations. The manager promotes a program focused on continuous survey readiness, emphasizing patient and staff safety, as well as the quality of services provided. Working under the direction of the Director, the manager will oversee day-to-day program operations and workflow. Collaboration with the Director, Endoscopy Managers, Regional Directors of Operations, Site (Medical) Directors, Content Experts, Risk Management, and General Counsel is essential to uphold organizational goals. The manager standardizes the process to ensure continual survey readiness across all United Digestive facilities. Directs all nursing services within the ASC.
REPORTS TO: Director of Endoscopy
Responsibilities
Duties may include but are not limited to:
Continuous Survey Readiness, Development, Management, and Oversight
As part of our commitment to excellence, the Endoscopy Operations Manager plays a crucial role in continuous survey readiness, resource development and management, and facility oversight.
- Ensure continuous survey readiness by leading facility evaluations and support of United Digestive's infrastructure and processes to achieve accreditation by accrediting organizations
- Address regulatory functions and identify vulnerabilities to ensure regulatory compliance
- Lead organization-wide accreditation and regulatory compliance efforts, and drive initiatives to resolve complex issues, aiming to inspire excellence in United Digestive Endoscopy Centers
- Develop tool kits and educational materials on survey readiness and regulatory compliance
- Conduct effective ongoing onsite mock surveys and regulatory compliance reviews per department calendar.
- Perform the CMS Infection Control Survey at least bi-annually at each assigned endoscopy center
- Ensure that United Digestive's regulatory resources are up to date by researching Quad A/AAAHC/JCAHO standards, Infection Prevention Strategies, the CMS Appendix L Interpretive Guidelines, and Life Safety Standards (All applicable NFPA guidelines)
- Design initiatives to evaluate and monitor compliance with regulatory standards through ongoing organizational assessment Focused Initiatives, tracers, mock surveys, and measurement data
- Oversee the development of an organizational communication and education plan for accreditation, which is designed to ensure continuous readiness, including website management and topics for survey update, tracers, etc.
- Serve as the main contact for standards-related materials and ensure that relevant information and material is disseminated to the appropriate individuals and roles. Educate Endoscopy Managers, Regional Directors, content experts, and key stakeholders regarding standards and regulations
- Plan and coordinate accreditation and regulatory surveys, serve as a liaison between accrediting bodies and the organization, develop and implement unannounced Survey Plan, manage onsite surveys and communications with surveyors
- Ensure that all ongoing application requirements and corrective action plans are managed
- Lead the development and implementation of action plans, including necessary measurement support, to address any issues identified by accrediting organizations and regulatory surveys
- Finalize and submit corrective action responses, in conjunction with the Director
- Collaborate with content experts and key stakeholders to ensure that corrective action plans are implemented and that measures are monitored to maintain accreditation
- Partner with Medical Staff Services to submit applications for accreditation with accrediting organizations and annual self-surveys
- Quad A Reporting & Self-Survey:
- Confirm PSDR’s are completed as required to remain compliant with Quad A
- Ensure unanticipated Sequela are promptly reported to Quad A via portal
- Perform Quad A self-surveys within the appropriate time frame to ensure continuous ASC accreditation Develop, implement, and manage any necessary corrective action plans
Health Care Safety Zone
- Monitor Health Care Safety Zone and ensure adverse events are documented properly and appropriate records are uploaded by the Endoscopy Manager for proper risk assessment
- Ensure that Site (Medical) Directors sign off on all adverse events per protocol
- Trend data and collaborate with Endoscopy Manager for quarterly QAPI reporting
- Use HCSZ data to propose performance improvement activities to Director for Endoscopy Governing Body approval.
- Actively manage or participate in two performance improvement studies per year
Endoscopy Manager and Charge Nurse Support in Partnership with the Regional Director of Operations: - Serve as a key resource nurse and leader in endoscopy workflows, accreditation, and regulation
- Demonstrate proficiency in all positions within the endoscopy center, including pre-op, endoscopy technician (in procedure room), endoscopy technician (scope processing), and PACU
- Collaborate with endoscopy managers and charge nurses to enhance their skill sets, support workflow needs, and strive for growth and improvement
- Coordinate and deliver effective presentations at manager meetings on relevant topics such as infection prevention, quality health care delivery, risk management, QAPI, and other endoscopy-related subjects
- Participate actively in the center’s quarterly QAPI meeting
- Focus on operational effectiveness by emphasizing efficient processes, cost containment efforts, and high-quality patient care. Share best practices across assigned centers
- Collaborate with the Regional Directors to develop a training plan for new Endoscopy Managers and Charge Nurses to ensure all responsibilities are addressed during the orientation period. In partnership with the RDO, confirm the following:
- The Endoscopy Manager/Charge Nurse has access to all programs necessary to perform their duties
- The training plan is implemented (including orientation at a sister center whenever possible) and, the new Endoscopy Manager has completed all aspects of their onboard training via post-training check-off list
- Confirm that Endoscopy Managers perform the following:
- Annual employee file reviews verifying all accreditation and compliance documentation requirements and create new employee files upon hire
- Annual training for high-level disinfection (scope handling and processing, manual reprocessing, and AER) is carried out and documented in the employee staff files
- Annual competencies are conducted and documented in the employee staff files by March 31
- Physicians and anesthesia personnel conduct peer reviews following the policy and procedures and report any adverse findings to the appropriate channels
- Quad-A daily log is maintained in a current fashion
- Performing routine pathology reconciliation and address issues promptly
- Conduct quarterly in-services on essential topics such as OSHA, infection prevention, and patient safety
- Gather and submit necessary documents and information for anesthesia and physician files to the medical staff services office
- Confirm that the Charge Nurses are prepared to manage the center when the Endoscopy Manager is on leave
- Confirm that the Charge Nurses can oversee the Endoscopy Unit temporarily in case the position for Endoscopy Manager is vacant
Endoscopy Center Cross-coverage And Staffing
- Stand-in as the Interim Endoscopy Manager if the Charge Nurse is temporarily absent
- Collaborate with the Director, the RDO, and Talent Acquisition to recruit a new Endoscopy Nurse Manager
- Work in partnership with Director and the RDO to shift staff for optimal coverage, as needed.
- Place orders online for Medely staff, once approved by the RDO, to ensure safe patient care within the endoscopy center
Required Education, Skills & Experience
ASN or BSN degree in Nursing. GI experience and clinical certification strongly preferred; strong management, interpersonal, organizational positive leadership, and effective communication skills are needed to be successful in this role; experience in project and budget management, operations management, surgery center management, or similar background preferred; flexibility and basic computer skills are necessary
Additional Skills And Experience
The Endoscopy Operations Manager must be able to:
- Provide a high level of customer service
- Plan, prioritize, and complete multiple tasks as delegated
- Work under pressure; assess, respond to, and communicate issues promptly
- Maintain composure and set a professional example for coworkers
- Communicate clearly with clients and coworkers through the telephone, email, and in-person
- Build positive working relationships with the administrative team, nurse managers, charges nurses, staff, and physicians
- Interpret and apply appropriate policies and procedures
- Be reliable, punctual, and able to work independently or with others
- Maintain the strictest confidentiality
PHYSICAL/MENTAL/ENVIRONMENTAL DEMANDS
The ability to work under stress, moderate periods of sitting and computer use, good visual acuity, and the ability to stoop, kneel, crouch, and/or crawl are required. Additionally, the ability to reach, grasp, use fine finger movement, and feel sensation to discern temperature, texture, size, and shape are necessary. The role also involves standing and walking for extensive periods of time, as well as lifting and carrying items weighing up to 25 pounds. Travel is required as business needs dictate.
