Director of Quality

About the role

The primary leader responsible for overseeing the day-to-day activities and leadership, coordination, and integration of services for WVU Medicine Hospitals. Responsible for directing the overall operation of departments and clinical areas which may include: Quality, Infection Control, Regulatory, Patient and Employee Safety, Risk Management, and/or Compliance and Privacy. Guides changes needed to reach each departmental goal for each hospital.

The Director of Quality provides overall organizational leadership for performance improvement and develops effective collaboration between all departments and affiliated services to ensure a quality-focused approach to providing services and fulfilling quality objectives. Functions as an effective liaison between medical staff, nursing administration, hospital leadership, and all other clinical and non-clinical departments. Develops new business/operational strategies to improve overall performance, reduce costs, enhance revenues, and achieve effective utilization and quality goals.

Responsibilities

• Administratively responsible for direction of all aspects of Quality, Patient and Employee Safety, Infection Control, Regulatory, Policy Management, Risk Management, and/or Compliance and Privacy.
• Leads by influence for effective Emergency Management and Life Safety to assure a hospital environment consistent with organizational objectives.
• Directs quality and regulatory initiatives through hospital administration and directors.
• Participates in operational planning and is responsible for development of goals and objectives for areas of accountability.
• Influences the establishment of standards of nursing practice and other clinical procedures within the hospital.
• Directs regular review of safety and quality outcomes and performance for both hospital's strategic plans.
• Directs and maintains application of the continuous improvement process in management of patient care delivery to achieve high quality, cost-effective services.
• Directs the preparation, control, and monitoring of budgets for assigned areas; assures compliance with targeted fiscal objectives.
• Recruits and develops staff necessary for effective leadership and management of departments to achieve hospital quality, safety goals, and regulatory requirements.
• Establishes and maintains standards for employee relations, motivation, and morale throughout the organization.
• Participates with governing body, management, medical staff, and clinical leaders in decision-making structures and processes.
• Collaborates with department managers and administrative team to provide recommendations for the annual operating and capital budget.
• Leads Risk Management administrative activities, including policy renewals and reporting issues to the carrier.
• Directs the Policy Committee and interprets hospital policies and procedures for administrative staff; implements new or modified policies as necessary.
• Assures applicable accreditation, licensure, and regulatory standards compliance.
• Presents evidence-based indicators and standards to measure, assess, and improve quality patient outcomes.
• Oversees and manages the administration, coordination, performance, and monitoring of operational and business activities of the entity.
• Works with leadership to identify improvement priorities and goals, delivering improvements to clinical and operational processes.
• Implements and manages clinical procedures and regulatory processes relating to patient flow, budgets, regulatory affairs, billing, and insurance.
• Develops and fosters effective collaboration between clinical departments and divisions to ensure an integrated approach to quality, safety, and performance improvement.
• Communicates effectively to facilitate positive working relationships and achieve desired outcomes.
• Oversees processes that provide relevant reports, data, and education to support quality improvement and fulfill reporting needs (e.g., national benchmark surveys, accreditation requirements, regulatory agency requirements).
• Supports key committees pertaining to investigation of sentinel events, safety concerns, and identification of event trends.
• Oversees the development and implementation of evidence-based medicine practice guidelines to meet quality of care, safety, and efficiency needs.
• Ensures compliance with relevant licensing, regulatory, and accreditation requirements; maintains knowledge and expertise in regulatory change.
• Assists in the development, coordination, and management of Emergency Operations Plans (EOP) and associated policies, ensuring compliance with standards set by regulating bodies (e.g., OHFLAC, TJC, CMS).
• Works with the Emergency Management Director/Manager to design, develop, coordinate, and implement hospital-wide training for EOPs.
• Assists in directing the execution of required hospital Emergency Preparedness.
• Represents the hospital at external meetings and venues at the local, regional, and state level.
• Develops and maintains a routine reporting process to the Board of Directors and administration with timely information on program status and periodic risk assessments.
• Coordinates and provides assistance with WVU Medicine initiatives.

Requirements

Minimum Qualifications

• Education: Bachelor’s degree in nursing, business administration, finance, accounting, or other related field.
• Experience: Five (5) years’ experience working with hospital operations with a focus in quality improvement. Three (3) years’ experience in leadership.

Preferred Qualifications

• Education: Master’s degree in business administration, finance, accounting, or other related field. Current licensure or temporary licensure as a Registered Professional Nurse.
• Experience: Ten (10) years’ experience working with hospital operations including at least five (5) years’ experience in Administrative Management. Experience in applying Lean Management approaches to process improvement.

Physical Requirements

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Requires full body ranges of motion, manual and finger dexterity, and hand-eye coordination.
• Requires sitting for long periods of time.
• Exposure to all patient elements including communicable diseases and body fluids.
• Requires corrective vision and hearing within normal range.

Working Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.

• Exposure to toxic substances, ionizing radiation, medicinal preparations, and other conditions common to a clinical environment.

Skills and Abilities

• Knowledge of financial mechanisms of expense and revenue.
• Knowledge of current theoretical approaches to the delivery of nursing care and strategies for their implementation.
• Knowledge of current leadership, management, and performance improvement concepts.
• Knowledge of the scope and complexity of nursing care needs of the hospital’s major patient population.
• Ability to investigate complaints, incidents, and accidents involving all patients and staff in accordance with hospital policy.
• Ability to make decisions and use good judgment.
• Requires multi-tasking, problem-solving, and decision-making abilities.
• Computer literacy and word processing required for the position.
• Excellent written and verbal communication skills.

Schedule

Scheduled Weekly Hours: 40