About The Position

The System Director of Quality directs and coordinates functions of all quality management functions for the system hospitals. Serves as an active member of the senior leadership team of the system interacting with the medical executive staffs, governing board, and other groups as appropriate. Is responsible for planning and implementing the Quality Assessment and Performance Improvement, and disease-specific programs to meet the needs of the system. Provides education to medical staff, hospital staff, and governing body. Facilitates performance improvement activities and continuous quality/readiness activities throughout the system hospitals. Acts as resource person to administrative teams, department directors, and medical staff. Oversight responsibility for all regulatory surveys, compliance with The Joint Commission, Centers for Medicare and Medicaid Services (CMS) Conditions of Participation, licensure and other standards, TDSHS, rules and regulations. Providers guidance and maintains overall accountability for specific designation compliance to include disease-specific designation/accreditation/certification.

Requirements

  • Three to five years of progressive quality leadership experience in a health care entity.
  • At least 5-8 years of clinical and quality improvement experience.
  • Excellent verbal and written communication and computer skills.
  • Strong organizational skills. Experience in coordinating activities across a range of entities.
  • Experience with, and knowledge of, hospital regulatory standards and related activities.
  • Ability to demonstrate critical thinking, appropriate prioritization and time management skills.
  • Ability to work under stress and to respond quickly in emergency situations
  • Working knowledge of healthcare laws and regulations.
  • Strong leadership, creativity, and excellent communication skills, written and verbal, with the ability to tailor the message to individuals and audiences across the organization.
  • Excellent analytical and problem-solving skills.
  • Ability to facilitate group and team process improvement activities.
  • Ability to establish and maintain long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations.
  • Must demonstrate commitment and adherence to STHS’s Compliance Program and Code of Conduct through compliance with all policies and procedures, the Code of Conduct, attendance at required training and immediately reporting suspected compliance issue(s) to the Compliance Officer.
  • Master’s degree in healthcare administration, business administration, finance, or clinical specialty required.
  • Certified Professional Healthcare Quality (CPHQ) required within twelve months of hire.

Nice To Haves

  • Additional training in data management, project management, and benchmarking preferred.
  • Previous experience within a multi-facility environmental preferred.

Responsibilities

  • Directs and coordinates functions of all quality management functions for the system hospitals.
  • Serves as an active member of the senior leadership team of the system interacting with the medical executive staffs, governing board, and other groups as appropriate.
  • Responsible for planning and implementing the Quality Assessment and Performance Improvement, and disease-specific programs to meet the needs of the system.
  • Provides education to medical staff, hospital staff, and governing body.
  • Facilitates performance improvement activities and continuous quality/readiness activities throughout the system hospitals.
  • Acts as resource person to administrative teams, department directors, and medical staff.
  • Oversight responsibility for all regulatory surveys, compliance with The Joint Commission, Centers for Medicare and Medicaid Services (CMS) Conditions of Participation, licensure and other standards, TDSHS, rules and regulations.
  • Providers guidance and maintains overall accountability for specific designation compliance to include disease-specific designation/accreditation/certification.
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