Executive Director, Quality Management Full Time NEW

The Executive Director, Quality Management collaborates in the strategic development and implementation of sustainable and effective clinical quality system management, programs, and initiatives in response to the changing needs of the University. This position is responsible for the implementation of improvement programs by using evidence based protocols and clinical care pathways that enhance safe, cost effective processes in the Hospital and/or Ambulatory Divisions. Contributes to areas that need to redesign processes and/or maintain processes in order to meet the continual changes of accrediting agencies, federal and state regulatory agencies and evidence-based practice.

Leads assigned quality system management operations for the enterprise, and responsible for the assigned unit’s deliverables. Provides direction and expert advice in the development and maintenance of clinical quality systems, programs, and initiatives that adhere to all legal and regulatory requirements and standards. Facilitates development of division-wide knowledge and education of key quality indicators, metrics, benchmark data, and reporting systems and tools. In collaboration with facilities, ensures development and implementation of appropriate accountability and reporting and processes within facilities. Contributes to the attainment of business goals by positively impacting continuous quality improvement outcomes. Optimizes use of resources, equipment and services, ensuring a high level of services. Actively seeks ways to contain costs and reduce unwarranted variation in care without compromising patient safety, quality of care, or the services delivered. Leads and makes decisions for effective implementation of division-wise strategies, programs, and initiatives related to clinical quality improvement to promote continuous readiness by assisting healthcare and medical staff on performance improvement on national, state, and locally reported measures, as well as compliance with quality national programs. Performs supervisory responsibilities in accordance with the University’s policies and applicable law. Responsible for interviewing, hiring, training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing and resolving problems. Leads initiatives to pursue the elimination of preventable harm by implementing high reliability organization techniques. Recognizes patterns, trends, and identify initiatives that impact quality improvement for the enterprise. Continuously monitors and evaluates quality outcomes and appropriateness of patient care throughout the division; identifying opportunities to improve outcomes. Alerts CPSQO if any identified outcome variances and assists in facilitating division response to quality issues, and incident reporting management. Establishes and continuously assesses the effectiveness of the internal controls within the unit and compliance with University policies and procedures. Ensures employees are trained on controls within the function and on University policy and procedures.

This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary.

CORE QUALIFICATIONS

Education:

Bachelor’s Degree in relevant field

Certification and Licensing:

Not Applicable

Required Experience:

Minimum 7 years of relevant experience. Clinical experience is required. Experienced with JCAHO and ACHA standards is required.

Knowledge, Skills and Behaviors:

• Ability to maintain effective interpersonal relationships
• Ability to communicate effectively in both oral and written form
• Skill in collecting, organizing and analyzing data
• Proficiency in computer software (i.e., Microsoft Office)
• Knowledge of business and management principles
• Ability to effectively plan, delegate and/or supervise the work of others.
• Ability to lead, motivate, develop and train others.

DEPARTMENT ADDENDUM

Department Specific Functions

Leads the overall hospital accreditation and regulatory survey readiness programs, and continuous quality assurance in either a primary leadership role, or as a secondary leadership support role. Assumes primary liaison between The Joint Commission (TJC) and UMHC on accreditation-related processes including but not limited to development of facility responses to survey findings, quality-of-care concerns, application submission, on-site visit and post-survey activity proceedings. Presides as Chairperson of the Accreditation Readiness & Response Committee (AR2C) and provides quarterly report to the Patient Safety Events Committee unto the UHealth Board of Directors. Identifies trends, gaps, and proactively develops programs with variety of constituents including hospital leadership, medical and nursing staff to improve organizational performance and compliance with accreditation and regulatory standards that impact quality and safety improvement for UMHC. Supports initiatives in pursuit of elimination of preventable harm by advising high reliability organization techniques. Drives short-term strategies that have long-term operational excellence impact on the achievement and sustainment of accreditation, program certifications and licensure. Translates accreditation, regulatory, and compliance strategies and procedures into actionable plans. Collaborates and advises senior leadership of outcome measures, matrix, performance improvement and effectiveness in alignment with UMHC and UHealth System Mission and Vision. Validates UMHC policies and practices through surveillance reviews for alignment and compliance with accreditation and regulatory standards. Presents survey readiness and compliance reports to UMHC leadership via a defined, formal reporting structure. Educates faculty, administration and staff relative to accreditation survey readiness; performance improvement; and, methods of collecting, analyzing, and reporting of data. Maintains current with accreditation and regulatory changes, evidence-based care practice guidelines and outcomes, and evolving professional and social issues in health care. Optimizes use of resources, equipment and services, ensuring a high level of services. Actively seeks ways to contain costs and reduce unwarranted variations without compromising safety, quality or services delivered. Verifies internal control compliance oversight of assets, policies and procedures, reliability of internal and external reporting, and efficiency and effectiveness of operations. Creates an effective control environment, conducts risk assessment, implements and monitors controls as appropriate. Oversees the department financial management, planning, operations, systems, and controls. Performs supervisory responsibilities in accordance with the University’s policies and applicable law. Responsible for interviewing, hiring, training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing and resolving problems. Other duties as assigned.