System Director, Quality
Directs the development and coordination of quality improvement programs (clinical, operational and service line) resulting in improved patient care, operations and patient experience. Responsible for providing strategic direction in all domains of practice including quality,, cost, service, operations. Oversees the development of strategies to improve public reporting. Directs the linking of Hospital improvement projects and initiatives to strategic priorities. Collaborates with Hospital and Medical Staff leadership on special projects relating to improved operations, processes and procedures. Provides direction, training and development involving all aspects of quality improvement.
- Reports to: Chief Medical Officer
- Provides Supervision to: Quality Review Specialists, Quality Manager and Junior Quality Manager, Quality project teams, interns
Essential Functions and Duties:
- Directs the development and coordination of quality improvement programs for system hospitals. Researches and recommends strategies and best practices and oversees the implementation of programs to increase patient care quality, excellence in operations and customer service across the system.
- Consults with various departments, service line leadership and committees on the design, structure and implementation of quality improvement programs across hospital sites.
- Leads and facilitates cross-functional teams focused upon the implementation of quality improvement initiatives designed to improve patient care, safety and overall operations; Consults on the redesign of systems and processes across the system.
- Work with Departmental Leaders to assure that these leaders utilize dashboards, balanced scorecards and data analysis methods (i.e., control charts, run charts) to accurately display and measure performance variables.
- Oversees the creation and production of physician profiles for use in ongoing and focused performance evaluations.
- Direct and serve as a quality expert in collaborative projects, grant initiatives, various committees and other hospital projects.
- Develops and leads the implementation of Quality University coursework and training programs for Hospital and Medical Staff leadership and the caregiver community on selected quality improvement tools, methods and techniques.
- Collaborates with various members of the Hospital’s global quality and patient safety team (i.e., Risk Management, Patient Safety, Nursing Quality, Operations, etc.) and assists with the planning and execution of the system Hospital’s quality and patient safety strategic plans.
- Works with Chairpersons of the System Clinical Quality Committee, System Hospital Quality Committee and other quality committees to establish agendas, dashboards and other meeting materials; Develops and presents quality improvement reports to the various Hospital and Medical Staff committees and assists in their preparation for Board meeting presentations.
- Supervises the work of Quality Review Specialists; oversees the Hospital’s compliance with Pay for Performance and Public Reporting requirements including the Core Measures Program, Hospital Acquired Conditions/Events, Patient Safety Indicators; Assures the integrity of the work performed in abstracting, submission to vendors, and education of medical and hospital staff on the requirements. Oversees vendor relationships for Core Measures and clinical decision support.
- Maintains compliance with accreditation and regulatory standards in the area of quality and other standards relevant to the work performed.
- Bachelor’s Degree in Healthcare Related Field; Master’s Degree highly desirable.
MINIMUM WORK EXPERIENCE:
- Minimum five-eight years experience in quality and/or operations improvement; 3-5 years of management experience which includes as a Director, Manager, Supervisor or in directing projects and teams.
KNOWLEDGE & SKILLS:
- Demonstrated leadership skills
- Demonstrated knowledge of quality improvement principles and practices (i.e., rapid cycle improvement, Six Sigma, Lean, balanced scorecards, etc.), project management, patient safety concepts, data analysis, data management and statistical process control in healthcare.
- Demonstrated knowledge of external regulatory and accreditation agency rules and regulations.
- Demonstrated knowledge of facilitating and coordinating healthcare improvement projects with previous quality improvement project experience at a system level
- Proficient computer skills with extensive experience using various software application such as MS Excel, Word, Access, Powerpoint; Crystal; reporting software ;High-level skill in the use of complex data in business/value development and the ability to analyze data and draw meaningful
- Excellent oral, written, “platform" and interpersonal communication skills. Ability to work independently.
- High degree of creativity in problem-solving.
REQUIRED LICENSES, Certificates, Registrations:
- Six Sigma, Lean, CPHQ certification preferred.