System Director-Quality

Baptist•Memphis, TN

111d

About The Position

Provides operational direction and guidance for Corporate Quality, Infection Prevention, Accreditation and Compliance, including Environment of Care, Quality Data and Analytics. Works closely with the Chief Quality Officer to implement comprehensive clinical quality and patient safety strategies, including standardization of care, regulatory compliance and accreditation, and identification of evidence-based practices across inpatient, outpatient, ambulatory, and post-acute settings where appropriate. Facilitates change through quality care delivery models, care coordination, improved patient outcomes, and improved financial performance by linking reimbursement to quality goals and measurements. Implements educational offerings and leads process improvement projects and activities. Partners with system and entity leaders, physicians, clinical leaders, interdisciplinary care teams, and other stakeholders to foster a culture of quality and safety, transparency, teamwork, measurement, and accountability across Baptist and its care settings. Supports Baptist’s mission, vision, values, and principles.

Requirements

Bachelor’s degree required.
At least 7 years of outcome-oriented experience in healthcare operations, including 5 years of quality management experience within a large- to midsize healthcare system.
Clinical license or designation required.
Knowledge of current healthcare legislation and policies, patient safety protocols, quality improvement methodologies, financial and reimbursement trends, and regulatory standards.
Ability to analyze, interpret, and clearly communicate complex quality and financial data to varied audiences and stakeholders across care settings.
Experience identifying quality performance drivers related to penalties and reimbursement, creating action plans, and delivering measurable results to reduce penalties and obtain reimbursement.
Experience with electronic medical record builds and clinically relevant report creation to improve clinical documentation, data capture, and workflows and to reduce PSIs, HAIs, CMS complications, mortality, and readmissions, and improve HCAHPS.
Experience with regulatory agency investigations involving patient complaints, implant or equipment recalls, agency reporting requirements, remediation, and processes to mitigate future safety events.
Knowledge and experience with continuous process improvement methodologies and tools, and ability to apply change management strategies in support of quality initiatives.
Understanding and experience deploying care coordination strategies, interventions, and tactics to improve efficiency and quality.
Excellent interpersonal and organizational skills and ability to establish and build internal and external relationships.
Strong group facilitation and conflict management skills, with demonstrated ability to unite individuals around a common vision or goal.

Nice To Haves

Master’s degree preferred.
Epic experience strongly preferred.
Registered Nurse (RN) desired.

Responsibilities

Provide operational guidance in developing, implementing, and evaluating quality improvement programs to enhance patient safety, improve health outcomes, and comply with regulatory standards.
Build and lead a high-performing Corporate Quality team focused on teamwork, communication, collaboration, program alignment, accountability, and operational effectiveness.
Participate in developing quality measurement systems and advanced technologies to strengthen data capabilities, improve operational efficiency, and improve outcomes.
Collaborate with the Chief Quality Officer, clinical and physician leaders, entity CEOs, and other stakeholders to validate organizational direction.
Research, evaluate, and recommend evidence-based practices focused on value-based care and reimbursement that improve quality, patient outcomes and experience, and healthcare costs.
Work with interdisciplinary teams to monitor system-wide quality and patient safety performance and improvement efforts.
Partner with hospital CEOs, CMOs, CNOs, clinical teams, physicians, and quality directors on standard data reviews, root cause analysis, and continuous improvement.
Identify care delivery gaps and develop and implement care coordination strategies for defined populations; evaluate quality improvements and health outcomes while promoting cost efficiency and appropriate resource utilization.
Develop and monitor key performance indicators and quality metrics, adjusting efforts as needed to meet organizational goals.
Lead multidisciplinary analyses of incident reports, root cause analyses, and failure mode and effects analyses; identify systemic vulnerabilities and implement corrective actions.
Analyze clinical data, identify trends, and implement evidence-based interventions to improve patient outcomes and healthcare delivery efficiency in acute, outpatient, ambulatory, and post-acute settings.
Design and implement patient safety initiatives, including infection control measures, medication safety protocols, and patient identification processes.
Promote a just safety culture in which safety concerns can be communicated and reported without fear of retribution.
Collaborate with Corporate Legal, Risk Services, and other stakeholders to analyze litigation and adverse-event trends, develop risk-reduction strategies, deploy action plans, and measure patient safety improvements.
Facilitate accreditation by ensuring patient care meets accrediting-body standards, preparing for site visits, conducting audits, and managing required documentation.
Develop, implement, and conduct training and educational offerings on quality and patient safety, process improvement, data and analytics, trends, and compliance and accreditation updates.
Perform other duties as directed or assigned.