Director of Quality PPMH

• Reporting to the System Chief Quality Officer, the Hospital Director for Quality is responsible for developing and implementing hospital-wide quality improvement, infection prevention, accreditation/regulatory, and patient safety programs to enhance healthcare outcomes and to create a highly reliable organization. Fosters a culture of safety, accountability, and continuous improvement across all levels of the organization. Collaborates with executive leadership across disciplines to set priorities and integrate quality program initiatives into operational plans. Mentors and develops the quality team to build their skill and competency. Uses data to drive change and sustain improvement. Maintains compliance with external regulations and agencies.
• EDUCATION REQUIREMENTS
  4 year Bachelor's Degree in in relevant field (Required)
  
  Master's Degree in in relevant field (Preferred)
• EXPERIENCE REQUIREMENTS
  Minimum in healthcare quality improvement, at least 3 years in a management role (Required)
• CERTIFICATIONS AND LICENSURES
  Preferred Certifications: Certified Professionals in Healthcare Quality (CPHQ) or attained within 18 mos. years of employment
  
  Preferred certification in improvement science e.g. LEAN Management

Essential Functions

• Oversees operations related to budgeting and position/staff management in assigned cost center
• Recruits and retains qualified team members; engages, develops, and mentors team members
• Establishes, maintains, and develops effective collaborative working relationships with all levels of leadership across the system, direct and indirect reports, and physicians/APPs to foster open communication and ensure the achievement of organizational and departmental goals.
• Actively seeks opportunities to expand knowledge base through professional development.
• Serves as a leader and resource for quality program knowledge and education across all disciplines and the community .

QUALITY IMPROVEMENT

Leads implementation of the annual Quality Assessment and Performance Improvement (QAPI) plan ensuring the allocation of resources to achieve success. Develops comprehensive, strategic and tactical plans to achieve hospital level progress in goal achievement; revises strategic plans accordingly. Utilizes and fosters use of evidence-based medicine to reduce unnecessary variation to standardize care and reduce costs. Inspires and guides team members through change while maximizing efficiency and effectiveness. Fosters a culture of flexibility, innovation, and continuous learning. Develops, participates in, and/or leads quality improvement teams/committees; drives the implementation of evidenced based prevention strategies and monitors process and outcome measures toward success. Collaborates with others across Phoebe Health System to inspire a system approach where appropriate Stay current on industry trends and best practices to ensure the organization remains at the forefront of quality and safety initiatives.

Accreditation/Regulatory Affairs

Partners with system and hospital leadership to ensure compliance with Federal and state standards and achieves a continual state of readiness Keeps abreast of all pertinent federal, state and hospital regulations, laws, and policies Manages regulatory compliance activities including preparation for survey, survey and follow-up documentation, corrective action planning/completion etc. Develops and maintains relationships with regulatory agencies and accrediting bodies

Patient Safety and Risk Management

• Partners with system and hospital leadership to lead a highly reliable organization and to achieve a goal of zero harm
• Engages in and fosters a culture of trust and transparency with the aim to reduce errors using just culture principles
• Conducts and/or leads others in root cause analyses, common cause analysis, failure mode effects analysis (FMEA), proactive risk analysis
• Ensures compliance with organization's incident reporting system in a timely and accurate manner.

Infection Prevention

• Develops comprehensive, strategic and tactical plans to achieve hospital level progress in goal achievement; revises strategic plans accordingly
• Supervises and coordinates hospital infection control surveillance to identify actual nosocomial infections, clustering and outbreaks of infection and infection potentials.
• Plans and provides education and guidance in infection control and prevention measures.

Ensures compliance with regulatory, accreditation and licensure requirements pertaining to infection control.

• Stay current on industry trends and best practices to ensure the organization remains at the forefront of infection prevention and control initiatives.

Data Analytics and Reporting

• Establishes and monitors key performance indicators across the organization. Oversees the collection, analysis, assimilation, and reporting of quality data to drive improvement.
• Provides scheduled reports and data to leadership, committees, and external agencies
• Partners in advancing analytical and technological solutions to improve data integrity and accuracy; standardizes quality reporting across the system where applicable.