Northern Light Health

Department: Quality Management

Position is located: Mercy Fore River

Work Type: Full Time

Hours Per Week: 40.00

Work Schedule: 8:00 AM to 4:30 PM

Summary:

The Director, Quality is responsible for leading the development, execution, and oversight of the quality strategy at Hospital. The position has oversight of patient experience, patient safety, risk management, and medical staff quality. This position will identify and implement quality and process improvement initiatives to achieve clinical excellence and patient experience goals for the organization working closely with the executive team, all nursing, physician and operational leaders and other key stakeholders to develop and implement effective change management strategies. The Director is responsible for maintaining a culture of positive communication and cooperation between physicians, advance practice practitioners, nursing, and other staff to ensure achievement of shared objectives.

This role will report to the Chief Quality & Patient Safety Officer with matrix reporting to the Senior Physician Executive for Hospital.

Responsibilities:

• Proficient in coordinating and managing reporting of CMS Core Measures, NHSN, CAHPS, Leapfrog, commercial payor quality programs and other quality metrics as needed.

• Lead improvement initiatives and direct the day-to-day execution of the strategies and tactics necessary to successfully improve patient safety and quality improvement outcomes and established goals for the organization.

• Monitor and maintain hospital-wide quality & patient safety program to include development of improvement plans, data collection, aggregating and analyzing data, maintaining policies and procedures, and reporting to executive leadership, Medical Staff, and the Board.

• Develop a comprehensive patient safety plan for the organization; monitor and identify trends; develop and implement mitigation plans in partnership with key stakeholders.

• Provide expertise and knowledge for administration, staff, and physicians in the areas of regulatory, process improvement, performance monitoring, and statistical analysis.

• Coordinate with Medical Staff Office the management and support of physician peer review processes by ensuring the collection and analysis of data for provider FPPE/OPPE, peer review, and department quality metrics.

• Participate in nursing and physician peer review processes and chart reviews, as needed.

• Provide recommendations to leadership based on patient safety and risk data for development of key performance indicators to evaluate and improve quality, clinical excellence, and patient experience for the organization.

• Use data from internal and external resources appropriately to develop overall goals for organizational quality program.

• Implement strategies to advance the organization towards high reliability and zero preventable patient harm.

• Has expert knowledge of value-based quality programs, risk-based payor contracts, prospective payment hospitals and value-based modifiers for hospital and ambulatory practices.

• Manage departmental budget, leading cost efficient and effective operations, and create plan of correction for expense variation.

• Maintain required competencies for self and all employees within the department.

• Complete annual performance evaluation for self and employees and implement plans of correction when needed.

Other Information:

• Process Improvement certification preferred.

• Healthcare Quality Certification (CPPS, CPHQ, CPXP, CPHRM) preferred.

• 5 – 7 years of professional experience required.

• 3 – 5 years of progressive management experience required.

• License or certification as required by discipline.

• Must be knowledgeable about Quality, Risk, and Patient Safety, and performance management and improvement.

• Knowledge of The Joint Commission and state regulatory standards is required. Candidate must demonstrate strong leadership and employee engagement skills.

Competencies and Skills

• Achieves Results: Sets high standards for their own outcomes and seizes opportunities to engage others towards objectives. Consistently moves forward with direct actions in order to attain or exceed objectives. Manages their own time effectively to accomplish assigned tasks. Successfully prioritizes multiple projects and duties as needed.

• Acts Strategically: Creates effective plans that anticipate future consequences and opportunities and is able to connect the day to day operations to longer-term objectives, shifts in the industry, and system goals.

• Applies Business Acumen:Demonstrates knowledge of current and future trends that impact organizational success. Applies proven practices and business theories to get results that meet financial as well as other business goals. Recognizes opportunities for new services and products and acts accordingly, taking measured risks into consideration. Possesses a thorough knowledge of their field and independently carries out their work in accordance with professional standards of the profession.

• Demonstrates Adaptability: Learns quickly when facing a new problem or unfamiliar task; is flexible in their approach with changing priorities and ambiguity. Manages change effectively and does not give up during adversity. Capable of changing one's behavioral style and/or views in order to attain a goal. Absorbs new information readily and puts it into practice effectively.

• Effectively Communicates: Listens, speaks and writes appropriately, using clear language. Communication methods are fitting to the message(s), audience, and situation and follow-ups are regular and timely. Shows that important (non-) verbal information is absorbed and understood and asks further questions to clarify when necessary. Expresses ideas and views clearly to others and has ability to adjust use of language to the audiences' level.

• Fosters Innovation: Employs and encourages the use of meaningful creativity in solving challenges. Proactively identifies opportunities and uses new approaches to enhance processes, systems and services. When appropriate, suggests or initiates new strategies, products, services, and markets.

• Influences and Inspires: Builds enthusiasm and commitment among others to move in a desired direction and models it personally. Creates a compelling vision of success that motivates workplace initiative and energizes others to follow. Provides direction and guidance to encourage cooperation between team members in order to attain an objective. Has the ability to appropriately influence others' actions and decisions with and without express authority.

• Promotes Health and Safety: Promotes a healthy and safe environment for patients, employees and visitors. Advocates and models healthy physical and mental health behaviors even in challenging circumstances. Sets high quality standards and strives for continuous improvement and quality assurance by reporting and encouraging others to report near misses and safety issues.

• Provides Patient-Centered Care: Demonstrates understanding of patient care quality and service as organizational priority. Proactively supports change to improve patient experience and results. Exhibits the ability and willingness to find out what the patient wants and needs and to act accordingly, taking the organizational and outside resources into account. Cooperates, collaborates, communicates, and integrates care within and between teams to ensure that care is continuous and reliable.

• Seeks Process Improvement & Applies System Thinking: Possesses and gains insight into situations, problems and processes. Understands the interconnection between organizational elements. Deconstructs problems and systematically investigates the various components. Considers the impact of actions on the entire process/system. Detects problems and opportunities, recognizes important information, and links various data to trace potential causes and relevant details.

• Utilizes Resources Effectively: Understands how to get the most out of available resources and uses cost-benefit thinking in decision-making and in setting priorities. Monitors and analyzes resource usage to identify and eliminate areas of waste and maximize resources. As a leader, defines targets and provides appropriate means; oversees progress and makes adjustments when necessary. Appropriately delegates work, sets clear direction and manages workflow and time.

• Behaves with Integrity and Builds Trust: Acts consistently in line with the core values, commitments and rules of conduct. Leads by example and tells the truth. Does what they say they will, when and how they say they will, or communicates an alternate plan.

• Cultivates Respect: Treats others fairly, embraces and values differences, and contributes to a culture of diversity, inclusion, empowerment and cooperation.

• Demonstrates Emotional Intelligence: Exhibits a high level of self-awareness, self-management, other awareness and relationship management. Conducts themselves in an empathic, appropriate way, with a sense of humor and stimulates a collaborative work environment. Is respectful of the attitudes, feelings, or circumstances of others and aware of the influence of their own behavior on them. Is aware of relevant social, political, system, and professional trends and developments and uses this information for the organization's benefit.

• Develops Self and Others:Takes responsibility for engaging in professional self-development activities and programs. Strives to gain insight into their own values, strengths and weaknesses, interests and ambitions and takes action in order to enhance competencies and skills when possible. As a leader, encourages and guides employees towards growth opportunities to enhance performance and help them reach goals. Reviews and analyzes employees' strengths and weaknesses to distinguish their talents and development needs, and to ensure they are enhanced appropriately.

• Exercises Sound Judgment & Decision Making: Understands and processes complex information, which allows for appropriate and accountable conclusions. Does not react too quickly or slowly. Balances facts, goals, and potential approaches taking the appropriate criteria into account. Makes active decisions and commits oneself by communicating confidently and respectfully.

• Fosters Accountability: Creates and participates in a work environment where people hold themselves and others accountable for processes, results and behaviors. Takes appropriate ownership not only of successes but also mistakes and works to correct them in a timely manner. Demonstrates understanding that we all work as a team and the quality and timeliness of work impacts everyone involved.

• Practices Compassion: Exhibits genuine care for people and is available and ready to help; displays a deep awareness of and strong willingness to relieve the suffering of others.

• Resolves Conflict: Promptly acts to find alternatives/solutions when team members disagree. Addresses issues in a direct, honest, and appropriate manner. Handles conflicting interests diplomatically and helps to solve them. Transforms difficult situations into teachable moments using respect and accountability .

Education

• Required Bachelor's DegreeIn nursing or clinical specialty. Master's degree in healthcare related field preferred.

Working Conditions

Position Dir- Quality MercyLocation Req ID null