Director, System Quality Performance

This person will report to the Vice President of Medical Affairs, and be accountable for the continuing development and effectiveness of key functional areas such as process reliability, improvement teams, regulatory performance improvement, quality metrics and analytics, patient safety and clinical transformation. The candidate will provide education and consultation on system-based process redesign and measurement for medical staff, management, co-workers, senior leadership, and board of trustees as part of the quality improvement process. The position interfaces with all hospital departments, medical staff and community to assure services are provided in compliance with hospital standards,policies, and procedures as well as regulatory requirements. This includes providing a planned, systematic, organization-wide approach to identifying, designing, measuring, prioritizing and monitoring all quality management activities including new processes and services.

• Education

Master's Degree in Health Related Field - Preferred

• Clinical Education in Health Related Field with Bachelor’s or Associate Degree - Required
• Experience

3-5 Years Hospital / Clinic - Required

• In addition, 3 years’ progressive experience in departmental leadership to a manager level or higher and demonstrated knowledge in the principles of quality management, performance improvement methodologies, and program evaluation.
• Working knowledge and / or experience in Medical Staff Quality Including Peer Review, Ongoing Professional Practice Evaluation, and Focused Professional Practice Evaluation.
• Experience in developing, implementing, and managing systems that support large-scale improvement programs, and leading clinical improvement activities in a highly integrated health delivery system.
• License & Certification

Professional License with State of Practice - Required

• Core Job Functions

Brings forward potential LSS projects from the system for council review. Works with leadership to prioritize LSS initiatives to support strategic goals.

• Plans, develops and implements performance improvement activities consistent with organizational and departmental goals and objectives. Evaluates department performance in terms of customer satisfaction, program attendance / completion rates and outcome measures that are based on appropriate benchmarks. Opportunities for improvement are identified and based upon data collected and analyzed and data and planning communicated with staff.
• Collaborates with committee chairpersons and assists in preparing agendas, minutes, follow-up, supporting documents and aggregate data for committee review and discussion and conducts follow-up as required for committee action. Assists medical staff with review and revision of approved screening criteria. Assists physicians with focused review, on-going review and special studies.

PI261196400