Director, Quality Initiatives & System Improvement

Hackensack Meridian Health•Hackensack, NJ

About The Position

The Director, Quality Initiatives and System Improvement provides oversight of hospital-based quality and patient-safety work to achieve strong clinical and patient-reported outcomes. The role builds organization-wide participation in improvement through transparency, collaboration, mutual learning, process redesign, data analysis, teaching, and mentorship. It directs the assessment, planning, implementation, monitoring, and evaluation of best practices to support cost-effective, quality care in accordance with the hospital Performance Improvement Plan and applicable regulatory and accrediting standards. Working in conjunction with and reporting directly to the regional Chief Quality Officer, the director oversees system quality activities, identifies areas for improvement, leads implementation and integration of the Department of Patient Care Performance Improvement Plan, and supports Joint Commission and regulatory compliance. The role also oversees Patient Safety and Quality Department activities, aligning them with Medical Center and HMH performance improvement plans.

Requirements

Master's degree in Nursing, Health Care Administration, Public Health, or another advanced health-related field.
At least 7 years of clinical experience in an acute care hospital.
At least 3 years of experience in patient safety and quality.
Excellent written and verbal communication and presentation skills.
Proficient computer skills, including Google Suite and/or Microsoft Office platforms.
Demonstrated leadership abilities.
CPHQ (Certified Professional in Healthcare Quality) or CPPS (Certified Professional in Patient Safety) certification.

Nice To Haves

Performance improvement expertise.
HRO experience.
Mastery of performance improvement methodologies.
Highly collaborative leadership style.

Responsibilities

Lead hospital quality improvement activities, including committee meetings, event management, follow-up of ONELink event reports, and improvement cycles.
Lead local high-reliability organization (HRO) transformation, engaging leaders, caregivers, and staff through HRO training, morning safety huddles, and integration of high-reliability principles.
Develop and oversee organizational quality initiatives and monitor quality priorities.
Present analyzed quality data and recommendations to organizational committees and councils, including the Department of Patient Care, to support HMH quality goals.
Oversee quality improvement staff and their work across quality councils, teams, and committees; promote continuous learning within and outside the network.
Ensure compliance with federal and state regulatory and licensing requirements, including Joint Commission readiness.
Promote continuous learning and transparency related to quality initiatives, including evidence-based best practices and scalable system improvements.
Guide hospital work toward HMH annual and strategic quality goals.
Ensure the use of appropriate methodologies and tools for rapid-cycle improvement, such as PDSA, FMEA, reliability science, bundle science, and process flows.
Collaborate with the Patient Safety and Quality Department and the VP, Chief Quality/Safety to implement organization-wide quality initiatives effectively.
Ensure effective performance-data analysis, including comparisons over time and against internal and external benchmarks, to identify improvement opportunities.
Oversee regular updates and educational sessions for physician and nursing leaders, managers, and team members on using monthly quality scorecard information and contributing to HMH quality goals.
Ensure trend analysis is completed and that appropriate responses to unfavorable trends are developed and deployed.
Develop and implement action plans based on analysis of data results.
Supervise staff education on relevant performance improvement theories and tools.
Ensure plans and designs meet internal and external expectations for accreditation, regulatory compliance, and public reporting.
Align performance improvement work with the Magnet philosophy.
Interview and hire Quality staff and manage performance evaluations.
Ensure Quality staff act in accordance with the Medical Center Code of Conduct.
Serve on the Patient Safety Committee, Performance Improvement Coordinating Committee, Nurse Executive Council, and Nursing Operational Committee.
Maintain professional growth and development through seminars, workshops, and professional facilitation to maintain and extend the expertise of self and team.