Director Quality Management II - Quality Management

CHRISTUS Health • Alamogordo, NM

1d

About The Position

The Director Quality Management II is responsible for the overall operations of quality management programs throughout Type B hospital facilities, including facilities with stroke support or acute care, Trauma Level 4, and/or specialty and high-acuity services under tertiary level, such as NICU Level 2, Trauma Level 3 or 4, and Primary Stroke Center. The quality management program encompasses quality, risk management, infection prevention, and safety. The director serves as a resource to management regarding guidelines for quality and safe patient care.

The role identifies and reports patient safety risk trends, collaborates with stakeholders to analyze safety risks and events, and implements action plans to mitigate risks. It uses internal and external data and validated change-management tools to drive performance improvement, and partners with leaders and clinicians to improve patient care quality and safety. The director operationalizes regulatory compliance processes, guides continuous survey readiness, and drives action plans to meet requirements. The role also ensures that facility policies and patient-care practices align with best-practice guidelines and standards set by State and Federal agencies and certifying agencies.

The position calls for effective communication with different audiences, computer proficiency with Excel, PowerPoint, MS Office, and flowchart tools, and knowledge of High-Reliability Principles, PDSA methodology, and payment models for quality metric performance. It requires advanced capability in quality leadership and integration, performance and process improvement, health data and analytics, regulatory and accreditation, patient safety, and quality review and accountability; population health and care transitions and professional engagement are identified at the proficient level.

Requirements

• Bachelor’s degree in Science in Nursing or another related field.
• Five years of healthcare experience.
• Two years of management experience.
• Three years of quality management experience.
• CPHQ (Certified Professional in Healthcare Quality) certification required or to be obtained within one year of hire.
• Proficiency with Excel, PowerPoint, MS Office, and flowchart tools.
• Knowledge of High-Reliability Principles and PDSA methodology.
• Knowledge of payment models for quality metric performance.

Nice To Haves

• Master’s degree preferred.

Responsibilities

• Oversee quality management program operations across the designated hospital facilities, including quality, risk management, infection prevention, and safety.
• Serve as a resource to management team members on guidelines for quality and safe patient care.
• Identify and report patient safety risk trends.
• Collaborate with key stakeholders to analyze patient safety risks and events.
• Implement action plans to mitigate patient safety risks.
• Use internal and external data and validated change-management tools to drive performance improvement.
• Collaborate with leadership and clinicians to improve patient care quality and safety using trended data and action plans.
• Operationalize processes that support compliance with regulatory standards.
• Facilitate continuous survey readiness and drive action plans to meet compliance requirements.
• Ensure facility policies and patient-care practices align with best-practice guidelines and standards from State and Federal agencies and certifying agencies.
• Communicate effectively with different audiences.
• Advance organizational healthcare quality through collaboration, learning opportunities, communication, and integrated quality infrastructure.
• Use performance, process improvement, project management, and change-management methods to support operational and clinical quality initiatives and organizational goals.
• Evaluate and improve healthcare processes and care transitions for defined populations.
• Use the organization's analytic environment to support data-driven decisions and quality improvement.
• Direct organization-wide monitoring and improvement of compliance with internal and external requirements, including preparation for, participation in, and follow-up to surveys and activities.
• Promote safe practices, a just culture, and processes that detect, mitigate, or prevent harm.
• Direct activities supporting organization-wide requirements for data acquisition, analysis, reporting, and improvement.
• Engage ethically in the healthcare quality profession, maintain competence, and advance the field.

What This Job Offers

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