Description
The Director of Enterprise Quality is responsible for aligning performance improvement initiatives with hospital goals and objectives, and developing, implementing and monitoring standards, procedures and processes to meet or exceed established clinical quality indicators, patient safety goals, and desired operational efficiency. Develops, implements and monitors standards, procedures, and processes to meet established clinical quality and safety goals. Ensures timely submission of information for pay-for- performance programs. Benchmarks hospital performance against national databases, such as NDNQI, Hospital Compare and NHIS. Demonstrates knowledge of federal, state, and accrediting agency standards and regulations that affect quality and performance improvement. Lead highly visible projects which will impact patient safety and clinical quality. Provide oversight of investigations for safety events using Root Cause Analysis methodologies; develop action plans and ensure implementation of identified improvements. Ensure that accurate data is available for the hospital to use to manage unit or division level performance for quality metrics. Coordinates and actively participates in process improvement activities to address performance gaps. Builds collaborative relationships among team members, nursing, ancillary departments, administration, and medical staff.
Requisition Type
Exempt/Non-Exempt
Responsibilities
Oversee activities that utilize cross-functional teams to identify, measure, analyze and improve core processes to support the organizations objectives for quality, patient safety and efficiencyEnsures that the necessary data collection and analysis is performedAnalyzes trends in clinical outcomes and patient safety and ensures that performance improvement activities are coordinated and supported to address findingsDemonstrates knowledge of federal, state, and TJC standards and regulations affecting reimbursement, quality, patient safety, and performance improvementApplies change management skills to influence formal and informal networks within Centra in support of quality and patient safety outcomesEnsures that internal and external research, investigation and analysis is conducted and information is presented in a concise and actionable formatManages development of department goals, budget, and scorecard metrics and targetsEstablishes and maintains collaborative relationships among team members, nursing, ancillary departments, administration, and medical staffRegularly communicates with management and staff regarding project status, issues and process redesign. Assists in the communication and training of Centra staff as it relates to patient safety and quality outcomes. Responds to all customers in a courteous, sensitive and respectful mannerEffectively uses conflict resolution skills, performance management techniques, and communication skills to resolve problems and promote teamworkStays current with industry and regulatory trends by subscribing to listservs, reading newsletters, and magazine articles, and reviewing information posted on the internet. Actively participates in activities with IHI, VHA and other external organizations as appropriate
Qualifications
Required Education: Bachelors of Science Degree in Nursing (BSN)Preferred Education: CPHQRequired Experience: Strong leadership and communication skills. Ability to read and interpret documents such as TJC, CMS, and industry articles. Ability to write policies, routine reports and correspondence. Ability to speak effectively before groups of nurses, physicians, other Centra employees, and outside constituents, such as TJC or CMS surveyors, peers from other hospital facilities. Aptitude with computers, the internet, and software such as Lotus Notes, Excel, and PowerPoint. An in-depth knowledge of patient care and documentation processesRequired Certifications and Licensures: Hold a current, active license as a registered nurse in Virginia or hold a current multistate licensure privilege as a registered nurse