Regional Director of Quality

Key Responsibilities

• Facilitates alignment between improvement initiatives and the organizations strategic plan; directs the day-to-day execution of the strategies and tactics necessary to successfully improve the outcomes and results of the organization.
• Responsible for maintaining the facilities system-wide Quality program; to include data collection, aggregating and analyzing data, maintaining policies and procedures and reporting to administrators, Medical Staff and the Board.
• Works closely with Clinical and Non-Clinical teams for improvement on key performance indicators, designs processes for new initiatives, services and other targets identified by Roosevelt General Hospital leadership.
• Serves as an internal consultant to administration, staff, and physicians in the areas of regulatory, process improvement, performance monitoring, and statistical analysis.
• Focuses on better healthcare value and quality, including the improvement of clinical outcomes, patient experience, patient safety, costs, revenue, productivity, efficiency, employee and physician satisfaction, and process reliability.
• Coordinate, manage and report Core Measures, ACO/MIPS/MACRA and meaningful use measures and other quality metrics as assigned.
• Collects and reports HCAHPS data for the facility.
• Organize all Quality Management meetings, maintain minutes and makes recommendations to the committee based on best practice and current regulatory standards.
• Conduct internal audits and risk analysis as determined by the Quality Management Committee.
• Participate in nursing and physician peer review processes and chart reviews, as necessary.
• Manage and support physician peer review processes by ensuring the collection and analysis of data for provider FPPE/OPPE, scorecards, quality metrics, etc.
• Analyze all assigned areas for opportunities of improvement and make applicable recommendations for process, system, procedure, and operational changes to improve healthcare value and quality.
• Assists in the establishment of operational performance measurements and the monitoring of trends in key performance indicators to evaluate effectiveness, reliability, efficiency, etc. using available information systems data.
• Where other data is necessary but not readily available, will design and implement appropriate data collection.
• Uses data from appropriate external sources, including comparative databases.
• Manages performance improvement projects, flow and alignment to assure milestones and key performance indicators are met within defined parameters. Documents the results of projects, and submits other documentation as requested.
• Participates in the Grievance Committee and works with department leaders to resolve investigations within the incident reporting system.
• Evaluate and document the effectiveness of the quality management system.
• Design, coordinate and maintain various aspects of the patient safety and risk management programs for all of the Hospital and its affiliated clinics.
• Review, investigate and analyze incidents for risk and adverse event identification, loss prevention and claims management purposes, including both potential and actual patient injury.
• Recommend interventions which will enhance the safety and well-being of patients, staff and organization at large.
• Mobilize departmental or administrative support to address unresolved high-risk practices.
• Collaborate and coordinate with administrators and other departmental leaders on all patient safety/risk management issues.

Knowledge, Skills & Abilities

• RN experience in a hospital setting
• Good communicator
• Strong accounting knowledge and experience
• Excellent in Excel (pivot tables, V-lookup’s, etc)
• Critical thinking and problem-solving abilities.

Work Experience, Education & Certifications

• RN License to practice professional nursing is required
• Registered Nurse with a strong analytical base, required
• A minimum of three (3) years’ experience in a hospital facility required, Quality/Risk leadership experience, preferred
• BSN required, Master’s degree in nursing, healthcare administration, or a similar field of study with a strong analytical base, preferred
• CPHQ (Certified Professional in Healthcare Quality), preferred