Reporting to the OHSU Knight Cancer Institute’s Director of Business Development and Planning, the Cancer Accreditation Manager is responsible for meeting and maintaining the American College of Surgeons Commission on Cancer accreditation, and other cancer-specific quality accreditations, for the OHSU Knight Cancer Institute and its five partner sites. This position is responsible for ensuring timely data submission to the CoC by required standards and reporting. The Cancer Accreditation Manager oversees the Business Data Analyst, responsible for accurate data and data analysis related to quality standards necessary for CoC compliance. This position will also work closely with the Cancer Registry to participate in strategic planning workgroups and committees, advising on cancer data.

 

This position will develop and foster strategic relationships with OHSU and partner site administrative and physician leaders to establish timelines and action plans for meeting accreditation requirements. The Cancer Accreditation Manager will report out and facilitate monthly and quarterly meetings related to the required cancer committees at all five sites. This position is also responsible for developing tracking mechanisms to ensure timely compliance across the sites and to ensure sites are proactively aware of upcoming reporting requirements.

 

This position will guide leadership proactively on updated standards and provide insights to support data-driven decisions regarding quality and accreditation. The Cancer Accreditation Manager will also lead the commission on cancer site visits at all sites and facilitate the completion of performance improvement plans necessary to meet rigid Commission on Cancer requirements.

 

The Cancer Accreditation Manager will also ensure the most recent advances and updates in the standards are met by maintaining expert knowledge of accreditation standard updates by working closely with and attending regular educational webinars.

Accreditation Oversight

• Oversees the Business Data Analyst (BDA3) and the data this position collects and reports out to ensure quality of the data meets the Commission on Cancer Accreditation standards. Manages the data visualization necessary for cancer committee meetings and works proactively with the BDA3 to ensure systems are in place for timely reporting for all standards are met.
• Acts as a liaison to medical staff participating in the Cancer Program at OHSU, Adventist Hospital, Bay Area Hospital, and Columbia Memorial Hospital; provides direction and leadership to the organizations by coordinating activities to maintain Commission on Cancer (CoC) accreditation and other accreditations as needed (for OHSU) and maintain compliance with their standards. Monitors on an ongoing basis, compliance level with standards, recommends and oversees implementation of activities and documentation to eliminate non-compliance.
• Participates in the planning of cancer committee meetings for OHSU, Adventist Health Portland, Bay Areas Hospital, and Columbia Memorial Hospital. Attends and participates in cancer committees and prep meetings. Provides physicians, administrative and ancillary support with guidelines on complete and timely documentation and Commission on Cancer (CoC) standards and other accreditation compliance. Prepares agenda and PowerPoint presentations for Cancer Committee quarterly meetings, attends as required member for the committee (CTR) and documents the minutes.
• Helps to achieve patient outcomes standards by contributing to cancer program goals, patient care improvement measures, accountability measures, assessment of evaluation and treatment planning, studies of quality and quality improvements.
• Works with leadership to meet community needs. Create and implement strategies to serve more people throughout the continuum of care via collaborated programmatic services.
• Collaborate effectively across all Cancer Programs to develop and/or enhance programs and service delivery in a coordinated way to best serve patients and the community.
• Commission on Cancer (CoC) Survey PRQ completion, point of contact for surveyor, prepare agenda for survey, take lead for chart reviews, and attend CoC Survey. Acts as point of contact for other accreditation to complete survey PRQ completions, point of contact surveyors, prepare agenda for surveys, take lead for chart reviews and attends surveys.

Strategic Planning and Data Analytics

• Actively participates in strategic planning processes and strategic initiatives by collecting, analyzing, summarizing, producing, and presenting data on OHSU and partner site tumor registry information (tumor information, locations) and Oregon State registry.
• Assess market and determine areas of opportunity/threat within the program.
• Propose and create innovative and appropriate data solutions (dashboards, reports, business intelligence tools, etc.) for the measurement of processes and outcomes.
• Assist in evaluation of Cancer Programs and other evidence-based health initiatives by carrying data analysis planning, implementation, and collaboration.
• Manage and complete requests from physicians for statistical analysis and clinical quality outcomes data used for quality improvement, enhancement of clinical pathways, research/abstracts, and manuscript publications

Cancer Data Management - Quality Data

• Serves as a subject matter expert on quality accreditation, cancer data management, and tumor registry requirements required for meeting local and national accreditation for OHSU and for smaller health systems across the state contracted through OHSU. Will engage with other health systems in determining current quality of their program and outline opportunities for improvement including OHSU managing their tumor registry service. In such cases, will oversee the development of the contract and will negotiate the cost of providing such services.
• Prepares and maintains policies and procedures related to the Cancer Programs Commission on Cancer for OHSU, Adventist Hospital, Bay Area Hospital, and Columbia Memorial Hospital, and for the National Accreditation Program for Rectal Cancer for OHSU.
• Attends training and educational meetings/conferences to uphold knowledge of changes and updates related to Commission on Cancer Program (CoC) Standards, National Accreditation Program for Rectal Cancer (NAPRC) Standards, and Cancer Registry functions. Actively participates in monthly department staff meetings, to include active participation in setting department goals and supporting department functions to meet set goals.

• Bachelor's degree plus two additional years of experience managing a cancer registry or CoC Accreditation oversight
• OR In place of a Bachelor's degree:
• At least 2 years of experience leading Commission on Cancer Accreditation cancer activities
• AND At least 4 years’ experience overseeing or working in a cancer registry.
• AND 2 years experience in cancer program development or project management within the healthcare setting, preferably around quality initiatives
• Minimum of 6 years professional experience, in the health care industry or related field

• Demonstrates ability to form relationships with physicians, administrators, and other allied health professionals; and to use tact and diplomacy to maintain effective working relationships.

• Ability to lead and manage complex, multi-institutional projects to completion.

• Ability to prioritize multiple tasks at one time.

• Excellent communication, documentation, organization, and planning skills; both written and verbal.

• Ability to work independently and as part of a team while being collaborative.

• Knowledge of current cancer registry management practice and operations; tumor nomenclature and strong medical background in cancer disease process.

• Ability to handle large volumes of highly detailed work with accuracy.

• Knowledge of all regulatory compliance standards and requirements, including National Program of Central Cancer Registries (NPCR), the Oregon State Cancer Registry (OSCaR), American College of Surgeons (ACoS) Commission on Cancer (CoC) and ACoS National Accredition Program of Rectal Cancer (NAPRC) rules, regulations, and standards.

• Knowledge of computerized database analysis, data processing, and database applications, including Oncolog.

• Knowledge of health care outcomes and quality improvement analysis.

• Knowledge and expertise in data analytics including data management and data analysis.

• ODS-C, Oncology Data Specialist - Certified

• Compliance with Code of Conduct, Respect in the workplace and Applicable policies, procedures and agreements related to position, department or OHSU as a whole

• Must be able to perform the essential functions of the position with or without accommodation

• Other certifications related to cancer registry, CoC, or other national quality certifications

• Work schedule M-F days. Mininum of one day per month in cancer registry office if home-based. Need to be able to travel to contracted sites annually if requested. Locations include Coos Bay, Astoria, and Hood River, Oregon.

Oregon Health & Science University values a diverse and culturally competent workforce. We are proud of our commitment to being an equal opportunity, affirmative action organization that does not discriminate against applicants on the basis of any protected class status, including disability status and protected veteran status. Individuals with diverse backgrounds and those who promote diversity and a culture of inclusion are encouraged to apply. To request reasonable accommodation contact the Affirmative Action and Equal Opportunity Department at 503-494-5148 or aaeo@ohsu.edu.