Director Quality

WVU Medicine•Burbank, CA

About The Position

The Director of Quality is the primary leader overseeing day-to-day activities and coordinating and integrating services for WVU Medicine Hospitals. The role directs the overall operation of departments and clinical areas that may include Quality, Infection Control, Regulatory, Patient and Employee Safety, Risk Management, Compliance, and Privacy. The Director provides organizational leadership for performance improvement, guides changes to achieve departmental goals, and fosters collaboration across clinical and non-clinical departments to advance quality objectives. The position also serves as a liaison among medical staff, nursing administration, hospital and entity leadership, and other departments. The Director develops strategies to improve organizational performance and supports cost reduction, revenue enhancement, effective utilization, and achievement of quality goals. Responsibilities include analyzing information to support management decisions, coordinating fiscal requirements and budget recommendations, and facilitating compliance with applicable regulatory bodies. The role leads improvement services, builds a culture of continuous improvement, and promotes practices intended to reduce errors and improve patient outcomes. The Director is administratively responsible for quality, patient and employee safety, infection control, regulatory affairs, policy management, risk management, and/or compliance and privacy. The position directs planning, goals, quality and safety reviews, continuous improvement, budgeting, staffing, policy administration, accreditation and regulatory compliance, reporting, and collaboration across hospital departments. The Director also supports emergency management planning, training, and preparedness in coordination with the Emergency Management Director/Manager, represents the hospital at external meetings, and reports program status and compliance risks to the Board of Directors and administration. The position is scheduled for 40 hours per week and is exempt. The work involves a clinical environment, including exposure to patients, communicable diseases, body fluids, toxic substances, ionizing radiation, and medicinal preparations. Physical demands include sitting for long periods, full-body range of motion, manual and finger dexterity, hand-eye coordination, and normal-range corrective vision and hearing.

Requirements

Bachelor’s degree in nursing, business administration, finance, accounting, or another related field.
Five years of experience working with hospital operations, with a focus in quality improvement.
Three years of leadership experience.
Knowledge of financial mechanisms of expense and revenue.
Knowledge of current theoretical approaches to nursing care delivery and strategies for implementation.
Knowledge of leadership, management, and performance improvement concepts.
Knowledge of the scope and complexity of nursing-care needs among the hospital’s major patient populations.
Ability to investigate complaints, incidents, and accidents involving patients and staff in accordance with hospital policy.
Ability to make decisions and exercise good judgment.
Ability to multitask, solve problems, and make decisions.
Computer literacy and word-processing ability.
Excellent written and verbal communication skills.

Nice To Haves

Master’s degree in business administration, finance, accounting, or another related field.
Current or temporary licensure as a Registered Professional Nurse.
Ten years of experience working with hospital operations, including at least five years of administrative management experience.
Experience applying Lean Management approaches to process improvement.

Responsibilities

Oversee and direct quality, patient and employee safety, infection control, regulatory, policy management, risk management, and/or compliance and privacy functions.
Lead by influence on emergency management and life safety to support a hospital environment consistent with organizational objectives.
Participate in operational planning and develop goals and objectives for areas of accountability.
Influence standards of nursing practice and other clinical procedures within the hospital.
Direct regular review of safety and quality outcomes and performance in relation to hospital strategic plans.
Direct continuous improvement in patient-care delivery to achieve high-quality, cost-effective services.
Prepare, control, and monitor assigned-area budgets; ensure targeted fiscal objectives and discuss variances and modifications with executive leadership.
Recruit and develop staff to support departmental leadership, hospital quality and safety goals, and regulatory requirements; establish employee-relations, motivation, and morale standards.
Participate in organizational decision-making with the governing body, management, medical staff, and clinical leaders.
Collaborate with department managers and the administrative team on annual operating and capital budget recommendations.
Lead risk-management administrative activities, including policy renewals, carrier reporting, and maintenance of related records and documents.
Direct the Policy Committee, interpret hospital policies and procedures for administrative staff, and implement new or modified policies as needed.
Ensure compliance with accreditation, licensure, and regulatory standards.
Present evidence-based indicators and standards for measuring and improving patient outcomes, and work with departments to approve and implement initiatives.
Oversee and manage the administration, coordination, performance, and monitoring of entity operational and business activities in collaboration with administration.
Partner with leadership to identify improvement priorities and goals and improve clinical and operational processes.
Implement and manage clinical procedures and regulatory processes related to patient flow and budgets, including regulatory affairs, professional fees, billing, insurance, and records maintenance and retention.
Foster collaboration between clinical departments and divisions to integrate quality, safety, and performance improvement efforts; communicate to support effective working relationships and outcomes.
Oversee reporting, data, and education processes that support quality improvement and fulfill national benchmark, ranking, accreditation, payer, regulatory, peer-review, and professional-practice evaluation requirements.
Support committees investigating sentinel events and safety concerns and identifying event trends; oversee evidence-based practice guidelines for quality, safety, and efficiency.
Maintain knowledge of regulatory changes and ensure compliance with licensing, regulatory, and accreditation requirements.
Assist the Emergency Management Director/Manager in developing and managing Emergency Operations Plans, annexes, and supporting policies that meet applicable regulatory standards.
Work with the Emergency Management Director/Manager and hospital education staff to develop and deliver hospital-wide and site-specific emergency operations training.
Assist and direct, with the Emergency Management Director/Manager, execution of required hospital emergency preparedness.
Represent the hospital at local, regional, and state external meetings and venues.
Develop and maintain routine reporting to the Board of Directors and administration on program status and periodic compliance risk assessments.
Coordinate and provide assistance with WVU Medicine.