Director Quality Improvement

POSITION SUMMARY

This position leads the Quality Department. This role elevates high reliability in clinical performance through assessment of performance, ensures prioritization of improvement activities, overseeing performance improvement projects and ensuring successful clinical project implementation at operating entities.

This position prioritizes clinical improvement activities, oversees the facilitation of performance improvement teams and successful implementation to achieve entity / system targets.

The position works closely with both system and operating entities to improve quality and outcomes of clinical care. This role requires strong communication, collaboration, teamwork and change management skills in order to achieve desired results across the continuum of care.

This position identifies and collaborates with senior leadership to prioritize appropriate resources related to opportunities in Peer Review investigations and other operational / clinical priorities to align performance improvement opportunities with system and local teams.

CORE FUNCTIONS

1. Quality Leadership and Integration - Lead the integration of quality into the fabric of the organization to achieve objectives such as Annual Initiatives, Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (JC) standards of care.

Directs and supports the quality infrastructure, protects the use of privileged or confidential information, oversees facilitation of processes for engagement and interprofessional teamwork, identifies and promotes continuous learning.

Collaborates with administrators, physicians, clinical leaders and team members to identify improvement opportunities utilizing qualitative and quantitative data analysis, knowledge of health care operations and systems thinking.

Understands the importance of strategic planning accompanied by relevant tactics to achieve the goals, even when midcourse changes occur.

Establishes and oversees the development and implementation of annual quality plans in partnership with administrative, service line and process owners.

Strategizes with entity leadership to plan and coordinate local Quality Councils / QAPIs.

2. Performance and Process Improvement Serves as a subject matter expert in performance and process improvement, project management and change management methods to support operational and clinical quality initiatives.

Manages, coaches, and oversees facilitation of improvement activities related to or resulting from patient safety, harm reduction, clinical performance opportunities, peer review and compliance with regulatory and accrediting agencies.

Serves as a resource and / or facilitates improvement teams to plan, implement, and coordinate entity activities to maximize clinical and operational outcomes.

Oversees and leads improvement teams, guiding teams on system defined improvement methodologies and processes.

3. Population Health and Care Transitions Directs evaluation and improvement of healthcare processes and care transitions to advance the efficient, effective and safe care of defined populations.

Directs the implementation of Clinical Practices and standardized processes, that are evidence-based Population Health management strategies, encourages and contributes to a holistic approach to improvement, collaborates to improve care processes, as well as, transitions back to the community.

Leads monitoring and reporting of facility Clinical Practice performance. Uses data to identify populations at risk and collaborates with interdisciplinary teams to develop strategies to improve outcomes.

Supports and participates in Clinical Consensus Groups at a system level to develop metrics for evidenced based practices for the enterprise.

4. Health Data Analytics - Leverages the organizations' analytic environment to guide data driven decision making and inform quality improvement initiatives while overseeing and guiding quality improvement initiatives and activities.

Oversees the collaboration with appropriate process owner(s). Ensures the acquisition and integration of data from internal and external benchmarking sources.

Uses statistical and visualization methods to analyze data for administrative and clinical decision making. Provides oversight of on-going assessment of performance, analyzes clinical outcome data, and identifies performance improvement opportunities or trends.

This role requires the ability to conduct and educate detailed qualitative and quantitative analysis.

5. Patient Safety Cultivates a safe healthcare environment by promoting safe practices, nurturing a Just Culture and improving processes that detect, mitigate or prevent harm.

Serves as an advocate for safety culture, ensuring the application of safety science principles / methods, identification and reporting of patient safety risks / events.

Oversees collaboration to analyze patient safety risks and events. Facilitates teams to improve processes that impact the safety of patients and team members.

Leverages results from patient safety investigations to coach entity leaders on safety improvement activities.

6. Regulatory and Accreditation - Directs the evaluation monitoring and improving compliance with internal and external requirements.

Oversees processes to prepare for, participate in, and follow up with Regulatory Agencies and certifications. Directs processes to support compliance with PI standards, ensures continuous survey readiness activities and oversees PI survey processes and findings.

This position collaborates and leverages results from regulatory opportunities.

7. Quality Review and Accountability Oversees and serves as a subject matter expert in compliance with voluntary, mandatory and contractual reporting requirements for data acquisition, analysis, reporting and process improvement.

Oversees current and emerging payment models as they relate to quality performance outcomes. Develops and communicates measurement requirements.

Supports practitioner and nursing peer review activities.

8. Professional Engagement - Engages in the healthcare quality profession with a commitment to practicing ethically, enhancing one's competencies and advancing the field by integrating ethical standards into practice, engaging in lifelong learning and participating in activities that advance the profession, such as participation in professional organizations and achievement of certification in healthcare quality.

9. Responsibilities cross all levels of internal customers including the department, facility and system, and external customers including but not limited to the medical staff, the community, regulatory bodies and state agencies.

Oversees and manages the department budget and productivity. Responsible for QI at a single entity or multiple entities and contribute to system level QI activities.

MINIMUM QUALIFICATIONS

Requires a Bachelor’s in nursing or other healthcare related field (i.e. : Pharmacy, Physical Therapy, Respiratory Therapy, etc.

and applicable master's degree.

If in a profession that requires licensure, current licensure / certification / registration is required for state worked.

Requires a proficiency level typically attained with five years acute care clinical experience. Requires at least two years management experience or demonstrated leadership abilities through

successful large-scale projects. Requires ability to perform complex statistical analysis and highly developed problem-solving skills.

Requires the ability to manage programs and projects. Requires demonstrated excellence in interpersonal and written communication skills.

Employees working at Banner Behavioral Health Hospital or the Whole Health Clinic must possess an Arizona Fingerprint Clearance Card at the time of hire and maintain the card for the duration of their employment.

PREFERRED QUALIFICATIONS

Registered Nurse (RN) license preferred. Certified Professional in Healthcare Quality (CPHQ) certification is preferred.

Experience with process improvement, regulatory / accreditation programs, data management, and analysis including graphic development and presentations is highly desirable.

Additional related education and / or experience preferred.

EOE / Female / Minority / Disability / Veterans

Our organization supports a drug-free work environment.

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