Senior Director-Health System Quality

Default Work Shift:

Day (United States of America)

Hours:

40

Salary range:

$85.24 - $129.48

Schedule:

Full Time

Shift Hours:

8 Hour employee

Department:

Quality Improvement

Job Objective:

Works in a dyad role, in collaboration with the Chief Quality Officer (CQO), to set the strategic direction for quality management, ensuring the highest standards of patient care, and fostering a culture of continuous improvement. Acts as the operational leader responsible for directing, implementing and overseeing initiatives to enhance all facets of quality improvement so that they align with the health system’s mission, vision, and goals. Under the leadership and support of the CQO is responsible for the development of an integrated approach to quality core functions including regulatory & accreditation preparedness, patient safety, infection prevention, quality review and accountability, performance & process improvement, population health management, value-based care, care transitions, health data analytics, and case management for the health care system.

Job Description:

Education: Required: Master’s Degree in Nursing Licensure/Certification: Required: California Registered Nurse (RN) License Preferred: CPHQ and/or Patient Safety, Project Management, and Lean/Six Sigma Certification Experience: Required: Seven (7) years of hospital management or equivalent management experience with current knowledge of regulations and standards as related to TJC, CMS Programs, California Department of Public Health, and other State and Federal agencies Preferred: Training in project management/lean or Lean/Six Sigma; experience working with clinical outcomes data systems and resource management

Reports To: Chief Quality Officer Supervises: Director of Quality Improvement/Patient Safety Officer; Director of Process Improvement; Director of Quality Analytics; Manager-Case Management; Manager - Social Work; Infection Preventionists; RN Outcomes Analysts for Physician Peer Review Ages of Patients: N/A Blood Borne Pathogens: Minimal/ No Potential

Skills, Knowledge, Abilities:

Ability to collect, analyze and disseminate data, including financial and statistical data, Ability to influence results and tactfully manage complex relationships and influences within and across the organization and system, Ability to prioritize fluctuating workload and times to meet position demands, Ability to set goals and work independently and efficiently with minimal supervision, Ability to work in a fast-paced environment and manage multiple meetings and projects, Interpersonal and relationship management skills to develop effective, collaborative and productive working relationships and partnerships with all levels of management and staff in the organization, Knowledge of performance improvement tools with the ability to use them effectively, Leadership and project management skills, Well-developed management skills, including the ability to recruit, retain, coach, mentor and direct a high performing team, Written and verbal communications skills

Essential Responsibilities

1. Works in collaboration with the Chief Quality Officer, Administrative Leadership, Nursing, and Medical Staff to implement programs and standards in identified quality and process improvement areas to include: Health System-wide performance improvement, infection prevention programs. 2. Supports development and maintenance of a culture of quality, safety and high reliability at all levels of the health system. 3. Advances quality and performance improvement throughout the health system by inspiring an environment of teamwork, trust, and transparency across the continuum of patient care. 4. Assists Quality, Process Improvement, Quality Analytics, and Case Management key stakeholders with opportunity analysis and development of strategic plans supporting quality & safety opportunities for the health system infrastructure that includes strategy, tactics, initiatives and deliverables. 5. Case Management resource stewardship, to ensure optimal allocation and utilization of resources. 6. Works with clinical stakeholders to ensure that Information Technology (IT) tools, including, but not limited to Electronic Health Records (EHRs), dashboards, reports, registries, and Health Information Exchanges (HIEs) serve both the documentation needs of clinicians while incorporating the need to provide data and feedback to support and demonstrate quality improvement in patient populations. 7. Ensures comprehensive and accurate data analysis and interpretation to support senior level decision-making regarding quality & safety opportunities. 8. Guides the Infection Prevention Program team for the health system ensuring coordination of infection surveillance, education, administrative, reporting, and control measures, including pandemic response. 9. Ensures that improvement science drives work within the Quality and Safety Division through analysis, research, and proper recommendations serving as an internal consultant in the evaluation and analysis of all current practice operations and quality processes. 10. Addresses core dimensions of national quality frameworks for population health to include the establishment and reinforcement of infrastructure for collaboration and innovation, definition and trending of populations, and improvement in transitions of care through care coordination across the health system and with community partners. 11. Contributes to the management of the State, and Federal accreditation, regulation, and licensing activities to include communicating the programs/processes to providers and medical staff, preparing of surveys and inspections, and completing assessments, and accurate and timely response plans and measures of success to include but not limited to, CMS, Joint Commission, and CDPH agencies. 12. Ensures summarized reports of performance and quality improvement data and activities are provided to the Board, health system administration, medical staff, and appropriate committees on a regular basis 13. Supports organizational primary service line certification and accreditation initiatives not limited to Cardiac, Orthopedic, and Cancer Care Services. 14. Supports patient satisfaction and implement service-oriented evaluation programs to facilitate excellent experiences for all customers. 15. Performs other duties as assigned.