Director of Quality

BHS•Richmond, KY

4d•Onsite

About The Position

The Director of Quality has operational and budgetary oversight for all areas of responsibility. Primary responsibilities include the development and maintenance of quality improvement program; coordination of performance improvement efforts to include patient experience, wound and ostomy care, infection prevention/control, pastoral care, peer review, and process excellence. Responsible for overseeing the operations of the department to ensure the provision of quality services and excellence in patient care. Serves as a leader, educator and mentor to physicians, directors and staff in promoting excellence in management of data, support quality of care, evaluation, outcomes management and in evidence-based outcomes across the organization. Responsible for overseeing the hospital quality improvement program. Ensures key processes and outcomes are tracked and reported in a timely and effective manner to physicians, staff, the hospital board and required external groups. Ensures compliance with all requirements of regulatory agencies associated with the quality department and keeps abreast of new and updated quality standards. Collaborates with other directors, physicians and staff to analyze interdepartmental data and support the development of action plans related to performance improvement initiatives. Participates in teams within the organization and system to achieve the goals of Baptist Healthcare System. Ensures that the staffing levels are maintained at an adequate level to meet the departmental needs. Monitors productivity levels and adjusts staff accordingly within budget. Responsible for financial management of the quality department including budgetary analysis of clinical outcomes data, developing and monitoring the departmental operating budgets and management of human resources and capital. Maintains a system of communication with administration, staff, and serves on various committees as requested or delegated. Serves as a liaison between outcomes and administration/other departments/vendors, etc. Analyzes benchmarked data and develops reports for internal and external customers identifying practice patterns, and other areas of concern with recommendations for improvement as appropriate. Develop systems and processes for timely and accurate data collection. Analyzes and interprets data that facilitates clinical practice patterns, communicates findings, and actively participates in areas for process improvement, solutions and implementation of solutions that positively impact patient outcomes. Attends all required safety training programs and can describe his/her responsibilities related to general safety, department/service safety, specific job related hazards, and national patient safety goals.

Requirements

Master’s degree in nursing required (or will be enrolled in an accredited Master of Nursing program within one year of hire with degree completion within 3 years)
3-5 years of healthcare management experience
3-5 years of clinical healthcare experience
Data management and data reporting experience required
Holds a certification as Certified Professional Healthcare Quality (CPHQ) or obtains within two years of hire
Proficient with computers, databases, and software programs

Responsibilities

Development and maintenance of quality improvement program
Coordination of performance improvement efforts (patient experience, wound and ostomy care, infection prevention/control, pastoral care, peer review, and process excellence)
Overseeing the operations of the department to ensure quality services and excellence in patient care
Serving as a leader, educator, and mentor to physicians, directors, and staff in data management, quality of care, evaluation, outcomes management, and evidence-based outcomes
Overseeing the hospital quality improvement program
Ensuring key processes and outcomes are tracked and reported to physicians, staff, the hospital board, and external groups
Ensuring compliance with regulatory agency requirements for the quality department and staying updated on quality standards
Collaborating with other directors, physicians, and staff to analyze interdepartmental data and develop action plans for performance improvement
Participating in organizational and system teams to achieve Baptist Healthcare System goals
Ensuring adequate staffing levels and monitoring productivity
Financial management of the quality department, including budgetary analysis, developing and monitoring operating budgets, and managing human resources and capital
Maintaining communication with administration and staff, and serving on committees
Serving as a liaison between outcomes and administration/other departments/vendors
Analyzing benchmarked data and developing reports for internal and external customers
Developing systems and processes for timely and accurate data collection
Analyzing and interpreting data to facilitate clinical practice patterns, communicating findings, and participating in process improvement
Attending required safety training programs and understanding safety responsibilities