VP of Quality Management

Catholic Health•West Islip, NY

About The Position

The VP of QM and Accreditation is responsible for planning, developing, and implementing performance improvement initiatives. The role provides facility-wide, multidisciplinary education and leadership for Operational/Leadership Rounding, FMEA, Six Sigma, and Lean projects; analyzes key performance measures and hospital-wide data; and leads department heads in quality performance initiatives and activities consistent with regulations and organizational mission and goals. The VP directs performance improvement activities associated with The Joint Commission standards, oversees hospital-wide laboratory Joint Commission accreditation surveys, serves as The Joint Commission Priority Focus Chair for Improving Organizational Performance, and responds to evidence of standard-compliance issues and complaints. The role also coordinates data registries for hospital service lines and oversees Quality Management Department personnel and activities. Other responsibilities may be assigned by the CMO to meet organizational needs. The position directs organizational preparation for Joint Commission accreditation, oversees disease-specific certifications and related surveys, and leads facility-wide improvement projects using PDSA, Lean, and Six Sigma. It analyzes and reports performance data, supports registry administration, develops policies and procedures, and provides leadership, coaching, and education to staff and department directors. The role supervises Quality Management staff, including hiring, training, evaluation, and competency assessment responsibilities. The position requires a master's degree and/or five years of experience in a healthcare setting, at least five years of administrative/clinical management experience, and at least five years of Quality or Performance Improvement experience. A NYS Licensed Health Care Professional license is required. CPHQ and/or CJCP are strongly preferred. The salary range is USD $300,000 to $385,000 per year. Catholic Health offers benefits including tuition assistance, a defined benefit pension plan, and a culture that supports professional and educational growth.

Requirements

Master’s degree and/or five years of experience in a healthcare setting.
At least five years of administrative/clinical management experience.
At least five years of Quality or Performance Improvement experience.
NYS Licensed Health Care Professional.
Knowledge of Outlook, Word, Excel, databases, and PowerPoint.
Ability to communicate effectively and professionally with all levels of staff.
Ability to analyze data, resolve issues, and use conflict-resolution and negotiating skills.
Qualified by experience and/or credentials to prepare staff performance evaluations and competency assessments.

Nice To Haves

CPHQ and/or CJCP certification.
Excellent organizational skills and attention to detail.
Credibility with physicians and professional staff.
Flexibility and dependability.
Problem-solving ability and creativity.
Effective communication and data-analytical skills.
Team-building skills and the ability to motivate, plan, organize, and direct the activities of others.
Ability to work in a stressful environment.

Responsibilities

Plan, develop, and implement performance improvement initiatives and facility-wide projects using PDSA, Lean, and Six Sigma.
Provide multidisciplinary leadership and education for Operational/Leadership Rounding, FMEA, Six Sigma, Lean projects, and performance improvement processes.
Collect, analyze, and interpret key performance measures and hospital-wide data; prepare and share reports in a timely manner.
Lead department heads in quality performance initiatives and activities that comply with regulations and organizational goals.
Direct performance improvement activities related to The Joint Commission standards and lead organizational preparation for hospital and laboratory accreditation surveys.
Serve as The Joint Commission Priority Focus Chair for Improving Organizational Performance and respond to compliance issues and complaints.
Oversee hospital-wide Joint Commission Disease Specific Certifications and associated surveys.
Coordinate, audit, and oversee data registry entries for hospital service lines, including the Adult Cardiac Surgery program, ACC NCDR, and Transcatheter Valve Therapy (TVT).
Develop meaningful performance improvement measures for clinical contracts and monitor contract performance data.
Represent GSHMC to CHS and LIHN in Quality Management matters and report quality, performance improvement, and contractual data to the CHS corporate Quality Meeting Committee.
Work with the Director of Quality Management and staff to develop and sustain projects addressing benchmark data from LIHN, The Joint Commission, CMS, DOH, and other sources.
Direct the overall functions of the Quality Management Department and develop, update, and review departmental policies, procedures, and forms.
Develop and administer systematic reviews and evaluations of Quality Management staff; interview and hire staff, prepare performance evaluations and competency assessments, and supervise training of new employees.
Lead and direct staff in accordance with department goals and policies, support administrative decisions and departmental changes, and check staff work.
Remain current with H-CAHPS literature and communications, serve as a root user for H-CAHPS reports, recommend dissemination methods for patient satisfaction information, and analyze aggregate data trends to identify improvement strategies.
Educate and coach department directors in process improvement methods and collaborate with them to improve employee, physician, and patient satisfaction.
Serve as a resource for staff, hospital personnel, and physicians; communicate professionally across staff levels and use conflict resolution and negotiation to resolve issues.
Attend continuing education programs, maintain current knowledge of hospital policies and Joint Commission and CMS standards, and investigate trends and innovations in Quality Management design.
Accept and perform other functions as requested by the CMO.