Director of Quality

JOB SUMMARY

The Director of Quality (DOQ) is responsible for ensuring quality healthcare is being administered to all patients. In charge of managing risk, ensuring compliance, controlling infection and improving the overall performance of Curry Health Network.  The DOQ ensures that policies and initiatives are efficient, safe, and reflect regulatory requirements.  Responsible for organizing and facilitating the personnel and work process of the quality improvement program for the entire organization. Has a detailed understanding and can skillfully use the techniques of system design, re-engineering, project management, quality improvement, outcomes measurement, and statistical analysis.

ESSENTIAL FUNCTIONS

Responsible for ensuring the facility is following DNV, state and federal standards.  Requires familiarity with DNV standards. Prepares the facility for DNV accreditation surveys.  Conducts readiness rounds in departments to ensure ongoing compliance with regulations. Acts as a resource person on regulatory guidelines. Interprets DNV standards for the hospital and assists with the development of policies and procedures to meet those standards. Serves as the hospital's liaison to DNV officials and other regulatory agency administrators. 

Provides oversight of Process Improvement activities. Chairs process improvement committee meetings and serves as a primary resource for the Medical Staff Quality and Peer Review Committees.

Oversight of Network’s reporting of quality and patient satisfaction metrics to external entities. Disseminates information to organization regarding metrics, goals and ongoing efforts to meet organization’s goals.

Oversight of complaint and grievances by facilitating resolution of family / visitor issues as well as maintenance of open communication with department leaders.

Oversight of CHN’s Patient Safety, Trauma, and Infection Prevention Programs, including Risk Management related issues.  Notifies CHN’s insurer when aware of a potential claim against the network.

Consults other departments, to discuss patient care and performance improvement activities.

Analyzes and accurately interprets data and metrics, using data and current evidence to drive decisions and priorities.

Establishes agendas and staffs the organization’s quality committee meetings, including the management team, the medical staff quality committee and the Board of Directors Quality committee

Other duties as assigned to support the overall effectiveness of the department and organizational performance in accordance with Curry Health Network’s Mission, Vision and Shared Values.

SHARED VALUES

Service:           We serve with compassion and understanding.

Teamwork:     We are one team – each one of us makes a difference.

Curiosity:        We promote learning.

Integrity:         We live by honesty, trust, and doing the right thing by our organizational values.

MINIMUM JOB REQUIREMENTS

Education & Experience

• BSN required; masters preferred
• A minimum of five (5) years’ experience in nursing position.
• A minimum of three (3) years’ experience in quality director leadership position required.
• Experience working with accreditation process, conducting mock surveys, and regulatory reporting required.
• CPHQ certification within 2 years of hire.
• Just Culture certification required within 6 months of hire
• Lean certified or Six Sigma training preferred.

Required Knowledge, Skills & Abilities

• Ability to communicate effectively in English, both verbally and in writing.
• Additional languages preferred.
• Strong written and verbal communication skills.
• Strong computer knowledge and ability, including Microsoft Office Suite required.

PHYSICAL REQUIREMENTS

Physical Demands

On-the-job time is spent in the following physical activities:

None of the time: Taste or Smell

Up to 1/3 of the time: Stand; Push/pull; Stoop, Kneel, Crouch or Crawl

From 1/3 to 1/2 of the time: Walk and Reach with Hands & Arms

Up 2/3 of the time and more: Sit; Talk or hear; Use hands to finger, handle or feel

This job requires that weight be lifted, or force be exerted as follows:

None of the time: up to or more than 100 pounds

Up to 1/3 of the time: up to 50 pounds

From 1/3 to 1/2 of the time: no requirement

Up to 2/3 of the time and more: no requirement

This job has special vision requirements as follows:

Close, distance, color, peripheral, depth perception and the ability to adjust focus.

Work Environment

This job requires exposure to the following environmental conditions:

None of the time: Extreme heat/cold; Wet/humid; fumes/airborne particles; work with explosives; vibration; outdoor weather; Working near moving mechanical parts; Toxic or caustic chemicals; Risk of electrical shock

Up to 1/3 of the time: no requirement

From 1/3 to 1/2 of the time: no requirement

The typical noise level for the work environment is: very quiet to moderate noise.

Hearing requirements: ability to hear alarms on equipment, patient call and instructions.

This job requires the following repetitive motion actions:

From 1 – 2 hours per day: foot control

From 3 – 4 hours per day: grasping: firm/heavy; fine dexterity

From 5 – 6 hours per day: grasping: simple/light

From 7 hours per day: hands