Director Quality and Performance Improvement

St. Joseph's Health • Paterson, NJ

1d

About The Position

The Director of Quality and Performance Improvement’s overall responsibility is to develop and direct an effective, comprehensive system-wide Performance Improvement Program. The Director of Quality and Performance Improvement provides administrative, organizational, clinical, and educational leadership in a manner consistent with SJH’s mission, vision, and values as well as the principles outlined in SJH’s foundational priorities and strategic plan. The Director of Quality and Performance Improvement functions as a dynamic leader of the SJH multidisciplinary leadership team to determine process improvements that will improve patient care processes and outcomes. This includes responsibility of daily operations and activities related to patient care processes and outcomes that impact quality of care, community perception and potential for revenue loss/gain. Scope of practice will include, but is not limited to the Provider Peer Review process, CMS inpatient and outpatient hospital reporting, (inclusive of value-based programs), Leapfrog Hospital Survey, NJ DOH quality reporting, proportionate shared programs, and Pay for Reporting incentive programs. The Director of Quality and Performance Improvement serving as a the leader of quality improvement initiatives will identify opportunities for improvement in care, upon access, during treatment, and transition of care accomplished through the collaborative efforts of multidisciplinary teams, Clinical Services, Ancillary Support Services, and Contracted Services. These opportunities will be identified by utilizing data analytics and to facilitate improvement of clinical and operational outcomes in order to implement process change/redesign, resource alignment or policies that improve patient care and/or services. This position offers a unique opportunity for an articulate innovator and effective change agent to work with clinicians, researchers, clinical and operational staff to develop and lead (strategic plan).

Requirements

• Registered Nurse (RN) license required
• Previous experience in leading Performance Improvement initiatives with a focus on process oriented activities that present opportunities for improvement
• Previous experience with Leapfrog criteria and survey submission process
• Certified Professional in Healthcare Quality (CPHQ) required
• Seven (7) years related experience of which five (5) years must be in a leadership role focused on care process indicators and outcome.
• Strong understanding of clinical operations
• 5 years of diverse clinical experience.
• Experience with a variety of methods and tools that support Performance Improvement activities.
• Strong understanding of Center for Medicare and Medicaid Services (CMS) Inpatient and Outpatient reporting programs and requirements
• Able to interpret legislative policy as it applies to CMS, NJDOH Quality monitoring and reporting
• Strong knowledge base of pay for performance programs
• Comprehensive knowledge of administrative data and implications of quality reporting
• Requires ability to perform complex statistical analysis and interpret data analytics
• Strong working knowledge of informatics and decision support techniques
• Familiarity with HCAHPS and other survey instruments that assess patient perspective of care
• Demonstrated track record of highly developed problem-solving skills.
• Requires the ability to manage programs and projects.
• Requires demonstrated excellence in interpersonal and written communication skills
• Working knowledge of NJDOH reportable safety events, patient safety initiatives, HRO facilitation, and DNV/ISO accreditation to support Patient Safety/Accreditation and Risk Management department activities

Nice To Haves

• Masters degree preferred

Responsibilities

• Develop and direct an effective, comprehensive system-wide Performance Improvement Program.
• Provide administrative, organizational, clinical, and educational leadership.
• Function as a leader of the SJH multidisciplinary leadership team to determine process improvements.
• Oversee daily operations and activities related to patient care processes and outcomes.
• Manage Provider Peer Review process.
• Oversee CMS inpatient and outpatient hospital reporting, including value-based programs.
• Manage Leapfrog Hospital Survey submission.
• Oversee NJ DOH quality reporting.
• Manage proportionate shared programs and Pay for Reporting incentive programs.
• Identify opportunities for improvement in care, upon access, during treatment, and transition of care.
• Utilize data analytics to identify opportunities for improvement.
• Facilitate improvement of clinical and operational outcomes.
• Implement process change/redesign, resource alignment or policies that improve patient care and/or services.

What This Job Offers

• Job Type: Full-time
• Career Level: Director