Director of Quality-Kishwaukee Hospital

Northwestern Memorial Healthcare•DeKalb, IL

5d•Onsite

About The Position

The Director Quality reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with relevant policies, procedures, guidelines and other regulatory and accreditation standards. Responsible for leading organizational quality efforts in support of NM and operating unit strategic goals. Functional areas of responsibility include clinical quality at the operating unit, and collaborative matrixed leadership of system functions at that operating unit, including infection prevention, risk management, accreditation/policy, patient experience and others as relevant. Reports to VP Quality NMHC and matrixed to Chief Medical Officer and Chief Nursing Executive at the local site. Responsible in collaboration with operating unit Chief Medical Officer and other leadership to develop, implement, monitor and achieve the annual NM and operating unit Quality Plan.

Requirements

Bachelor’s degree in relevant field (RN, RPh, health administration, public health, etc)
Master’s degree in relevant field (or, rarely, equivalent experience and demonstrated ability)
3+ years of experience leading clinical quality and patient safety in a large and/or complex environment, including evidence of effective improvement initiatives
Leadership, personnel management, and change management skills
Project management, facilitation, and analytical skills
Statistics, quantitative and analytic skills relevant to the role
High level of energy and enthusiasm; flexible/adaptable – ability to work with diverse group of healthcare professionals in a matrix environment
Effective problem solving, verbal and written communication skills
Ability to manage multiple large and demanding projects/functional areas in a well-organized manner, with successful outcomes and collaborative teamwork

Nice To Haves

5+ years of relevant experience
Evidence of publishable work
CPHQ, CPPS, or similar certification or evidence of professional commitment

Responsibilities

Lead, plan, and direct and coordinate the Quality programs at designated operating unit(s)
Collaborate with operating unit CMO(s), CNE(s) and system leaders
Scope includes all patient care and the functions which support patient care
Scope includes all practitioners, clinicians and others participating in delivering or supporting patient care, including those privileged through the medical staff, trainees, students, employees, volunteers
In collaboration with operating unit leaders and others, develop, implement, manage and achieve annual Quality plan, and other supporting plans.
Collaborate in advancing the work of system functions at operating unit, including Risk Management, Infection Prevention, Patient Experience and Accreditation/Policy Management.
Support and interface with Health System Clinical Collaboratives to advance quality and related goals and plans at the operating unit
As assigned, take leadership in advancing selected projects on a regional or system-wide level
Design, lead, implement, teach and monitor NM quality and safety practices, policies, protocols and methodologies.
Support Board accountability and reporting as assigned.
Develop reports, materials, and support for Board of Directors related to the local site’s quality goals and progress and challenges.
Manage/oversee medical staff OPPE, FPPE, peer review program and assure consistent application across sites and disciplines.
As relevant and as agreed with operating unit / regional leadership, lead or collaborate in advancing the Patient Family Advisory Council and patient experience initiatives.
Implement surveillance and reporting to identify areas of concern and strength.
Monitor internal and external trends to identify priorities.
Set and achieve appropriate goals for quality, patient safety, and innovation.
Implement, facilitate and advance work of quality committees and quality plans.
Accountable for federal/state and other mandatory reporting in the Quality (e.g. Medicare measures); other mandates in collaboration with system manager for Accreditation.
Assure and support appropriate public transparency and reporting of quality data.
Plan, lead and direct improvement initiatives, innovation and transformation activities.
Assure compliance with all relevant clinical accreditation, certification, and licensure standards.
Recruit and develop staff, teach/orient/train, manage financial and human resources efficiently and effectively.
Oversee effective use of budget and other resources as delegated.
Maintain high levels of staff engagement and performance.
Collaborate effectively across the system, including but not limited to directors and managers of quality / performance improvement / analytics, chief medical officers, chief nursing executives, operations executives.
Advance the standard of quality and safe patient care across NM through innovation, learning and shared deployment of best practices.
Contribute to national understanding of quality through publication and presentations