Director Quality and Performance Excellence

Job Summary: The Director of Quality and Performance Excellence is responsible for continual improvement in the quality, safety and satisfaction of care delivery, in their assigned facilities. Facilitates performance improvement activities and CQI activities throughout the hospital. Acts as a point of contact to the administrative team, department managers and medical staff. Provides administrative oversight to the facility Risk Manager. Will assist in facilitating all regulatory body surveys, i.e., TJC, State Licensing Review, and CMS Validation surveys as needed. Leads the design, planning, implementation and coordination of Quality Management and Performance Improvement activities for assigned hospitals and medical staff departments, committees, service lines and functions.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.

Essential Functions:

• Proactively coordinates and facilitates performance improvement teams to support key initiatives, including but not limited to, activities focused on clinical quality improvement, patient safety and risk reduction, patient experience, efficiency, FMEAS, and root cause analyses and medical staff improvement (e.g. OPPE, FPPE)
• Participates in an integral role in concert with the Manager of Risk and Regulatory, System Manager of Clinical Outcomes and Data Analytics, local leadership, to ensure compliance with CMS, TJC, Leapfrog, etc., data collection and reporting of process and outcome measures.
• Facilitates development and implementation of data collection tools and processes including the ability to: identify data elements needed to complete appropriate measurement, perform data collection and abstraction per specifications, and validate data prior to submission or preview reports prior to publication.
• Facilitates meetings, presents data and reports, identifies key findings and assists with action plans and implementation.
• Establishes policies and procedures consistent with the Quality and Performance Improvement initiatives and objectives of the facility and ensuring their execution.
• Evaluates the results of overall performance improvement activities regularly and systematically and reporting these results to Corporate Sr. Director of Quality and Risk Management as well as executive leadership, Medical Staff and Governing Boards.
• Ensures that the responsibilities, authorities and accountability of all direct subordinates are defined and understood.
• Ensures the overall direction, coordination and evaluation of the subordinate units/departments.
• In consultation with the Human Resources Department and legal counsel, develops disciplinary measures for noncompliance (including the failure to prevent, detect, or report any noncompliance), appropriate to the nature and extent of the deviation, and assuring consistency in the application of disciplinary action.
• Manage periodic reviews of all standard operating procedures and perform internal audits.
• Manage and maintain the status of all audit findings and ensure prompt response & resolution.
• Improve effectiveness, efficiency, reliability, and productivity on a continuous basis.
• Lead/coordinate investigations, and the development and implementation of corrective and preventative action (CAPA) recommendations.
• Manage Performance Improvement (PI) activities and projects.
• Oversee the Quality Committee and PI Teams.
• Provide summary reports to management of all PI activities.
• Develops annual Quality Assessment Performance Improvement plan (QAPI), annual evaluation, Key Quality Indicators, reporting calendar and interfaces with cross-functional teams to coordinate the operational support and resources needed to reach quality performance goals.
• Develops mitigation plans in partnership with operational areas to address performance deficits.
• Reviews patient charts through a critical lens and evaluates gaps in care for compliance based on measure specifications and to ensure clinical staff are completing tasks per established guidelines.
• Works with analytic and reporting teams to ensure appropriate reports, performance and data analysis are produced to increase efficacy of performance improvement efforts and to facilitate attainment of quality program goals.
• Oversee the peer review process in coordination with the Chief Medical Officer and Medical Staff Office.
• Responsible for overseeing the data collection and submission for all core measures, public reported data and audits.
• Develops education for provider partners and internal staff on quality initiatives.
• Responds to coding, documentation related questions from clients and staff with appropriate information provided in a timely and accurate manner.
• Collaborates with Sr. Corporate Director of Quality and Risk Management in the development of and supporting performance improvement activities for the facility.
• Ensures that all organization activities and operations are carried out in compliance with local, state and federal regulations, TJC standards and laws governing healthcare operations.
• Is responsible for interviewing, hiring, assigning and directing work, counseling, appraising performance, rewarding and disciplining personnel.

Behavioral Standards:

• Strong understanding of QI/RM principles and practices.
• Participates and provides leadership in concert with the Manager of Risk and Regulatory, Infection Prevention with regulatory readiness and survey preparation activities including mock survey tracers.
• Provides support and assistance to medical staff officers, committee chairpersons and Governing Body, as required.
• Utilizes information obtained via performance improvement activities to seek and act on opportunities to improve patient care processes.
• Ability to identify and assess potential risks to patient safety.
• Demonstrates the highest level of professionalism, passion and care when interacting with patients, families, physicians, and hospital staff members.
• Using a lens of equity in all aspects of patient care delivery, education, and research to promote policies and practices to allow opportunities for all to thrive and reach their potential, embracing ingenuity to service our customers.

Communication/Knowledge:

• Maintains open lines of communication with subordinate departments.
• Demonstrates effectiveness in planning and implementing the performance improvement program to meet the needs of the hospital.
• Demonstrates knowledge of current performance improvement methodology and practices. Maintains awareness of changes in the regulations and requirements by accrediting bodies.
• Demonstrates use of database systems to document occurrences, medical staff review functions, committee review and actions. Compiling reports for committees, Governing Board and administrative team.
• Consults with other departments as appropriate to collaborate in patient care and performance improvement activities.
• Maintains current knowledge of accreditation and licensing requirements and must be a resource to staff on these regulations to improve management of outcomes and ensure compliance.

Collaboration/Teamwork:

• Maintains an environment of collaboration and cooperation among hospital departments.
• Contributes toward effective, positive working relationships with internal and external colleagues.
• Demonstrates cooperation, flexibility, reliability, and dependability in all daily work activities and a willingness to collaborate with others for the good of the customer and the organization.

Qualifications/Experience:

• Minimum of five (5) years of experience in Quality Improvement and/or Risk Management.
• Five (5) years of experience in a leadership role.
• Critical thinking, service excellence and good interpersonal communication skills, ability to read/comprehend written instructions, strong organizational skills, ability to follow verbal instructions, and PC (computer) skills.
• A capacity to learn, synthesize, make critical judgments, work independently, place patients and families first, and collaborate with the team members who are recognized leaders within healthcare.

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