The Senior Director of Quality is responsible for the oversight and management of the following Departments/ Department Directors/Leaders: Medical Staff Services, Infection Prevention, Risk Management and Quality. The position requires at least 10 years’ experience in related areas as well as at least 5 + years in a leadership position. CPHRM, CPHQ, CIC, or other hospital related certification strongly desired. Extensive experience with CMS Conditions of Participation-interpretation, maintaining compliance, action plans, etc. as well as knowledge of core measures, infection prevention/NHSN reporting, credentialing requirements, and risk management matters. Ability to lead with positive influence.
• Oversee infection prevention, quality management and risk management and medical staff services.
• Ensures compliance with all applicable regulatory standards within the hospital.
• Determines the quantity, qualification, and competence of department personnel.
• Ensures Administrative Policies and Procedures are appropriately administered in assigned areas.
• Maintains a positive work environment and promotes team efforts.
• Demonstrates effective leadership skills of delegation, organization and coordination in managing multiple departments.
• Direct/assist with quality management/utilization review and ensure patient quality/safety is maintained.
• Oversee quality improvement and accreditation and develop the quality improvement annual plan for the hospital, which is in accordance with Federal and Texas laws, regulations and the CMS accreditation standards.
• Coordinates the Quality Improvement Committee and medical staff activities.
• Chairs the Departmental Quality Committee.
• Provides quality data to the Executive team as requested.
• Budgets for hospital quality improvement and the CMS accreditation needs.
• Works with medical staff and hospital staff in the Implementation of the hospital quality and accreditation programs.
• Supervises, directs and evaluates, and hires quality and departmental staff in their performance of their work.
• Oversee the organization, analysis and management of all Risk Management Patient Safety activities of all locations.
• Acts as a subject matter expert, resource, internal consultant, and educator for risk management issues.
• Identifies strategies and solutions to enhance the healthcare operations environment and initiates techniques to reduce exposures to risks.
• Provides consultation and assistance to facility leadership, staff, and physicians on day to day risk management issues and provide assistance to System Legal and Risk Management Services as needed.
• Serve on appropriate clinical and non-clinical committees where risk management expertise is beneficial in a capacity of expert advisor or consultant or attend as appropriate.
• Review and recommend new or amended policies and procedures including providing support for the policy and procedure committee.
• Participate in and support Emergency Preparedness initiatives.
• Support system Risk Management goals and objectives as well as facility-based goals which contribute to the achievement of the overall strategic objectives of the organization.
• Oversee and ensure that all aspects of the credentialing, re-credentialing and privileging processes for all medical providers who provide patient care at LHSH, NorthStar and TPG are in compliance with all regulations.
• Additional duties as assigned.
MINIMUM KNOWLEDGE AND SKILLS REQUIRED:
• Knowledgeable in the principles of human resources administration, quality assurance and performance improvement.
• Ability to communicate effectively both verbally and in writing.
• Ability to establish and maintain effective relationships within and outside the organization.
• Effective public speaking skills, as well as ability to develop and conduct effective presentations.
• Excellent interpersonal communication, problem solving and conflict resolution skills.
• Possession of analytical decision-making skills necessary to quickly assess and resolve complex logistical, technical problems and issues.
• Ability to train, motivate and supervise subordinate staff.
• Ability to address and manage conflict in a direct and professional manner.
• Ability to build collaborative relationships with providers.
• High emotional intelligence as evidenced by ability to evaluate/perceive a situation from multiple lenses and understand various perspectives in coming to problem resolution.
MINIMUM EDUCATION AND EXPERIENCE REQUIRED:
• Master’s degree preferred in Nursing or Health Care related field required from an accredited college/university.
• At least 10 years’ experience in related areas.
• 5 + years’ experience in upper level management at a comparable or larger facility.
LICENSURE AND CERTIFICATION:
• CPHRM, CPHQ, CIC or other hospital related certification strongly desired.
ENVIRONMENTAL AND PHYSICAL REQUIREMENTS:
• The employee works in a temperature controlled environment.
• Must be able to read, write and speak English fluently, have cognitive skills for math. Vision for near, mid-range, far and accommodation. Hearing for low, medium, and high pitch.
• Communication skills to deal well with employees, patients, families and physicians.
• Job requires physical ability for standing, sitting, crouching, kneeling, frequent walking, reaching with reaching above head and below waist.
• May be occasionally subject to irregular hours.