Director of Quality

Overview

The Director of Quality provides direct oversight of Quality Management, Risk Management, Infection Prevention, and Case Management. This position oversees all Patient Safety and Culture of Safety initiatives, as well as accreditation and licensing and Medical Staff Peer Review. Other essential functions include oversight of all data abstraction, data analysis, internal, external, and regulatory quality data reporting, and oversight of department team members who contribute to these functions. This role ensures the department team members have the right level of skill development, right processes and systems in place to ensure both effectiveness and efficiency in job performance. They are responsible for ensuring an adequate budget for these functions and ensure that evaluations and competencies for all staff are completed. This leader ensures a healthy work environment where team members thrive. They work collaboratively with other leaders, Medical Staff and the Board Quality committee to ensure that data is collected and reported in a timely manner. This position also acts in a consultant capacity with leadership to enable all areas of the organization to achieve and maintain optimal quality using evidence based practices.

Responsibilities

Provides consistent leadership and management for the quality and case management departments. Provides direction, coaching and support to staff regarding professional standards, work quality, performance and accountability; collaborates on resolving problems and/or performance gaps; develops annual staff engagement improvement plans; and engages in regular communications (department meetings, one-on-ones, performance feedback).  Foster professional growth through skill development and continuing education.   Support and guide initiatives to improve and maintain high employee engagement.

 

Provides leadership for organizational performance on quality, risk, and utilization metrics.  Fosters an environment of openness, interdisciplinary collaboration and accountability which encourages safe, effective and efficient care delivery. Coordinates efforts to standardize monitoring, analysis and reporting. Provides dashboard metrics to medical staff, contracted groups, and leadership.  Assists departmental leadership to improve patient care processes to meet or exceed national and state benchmarks.

 

Actively seeks to improve department performance. Assists  leaders and supervisors/coordinators in developing and maintaining quality monitoring, performance improvement,  skill development and continuing education, and compliance with regulatory standards. 

 

Facilitates the conduction, dissemination and utilization of research to ensure evidence based practice within care coordination and throughout the organization. 

 

Maintains current knowledge and communicates changes in regulatory standards to leadership and ensures that processes are in place to address these changes.  Ensures a process for policy and procedure review and updating throughout the organization and leads accreditation efforts.

 

Serves on medical staff committees, reports to Board Quality Committee and other committees as needed. Provides a forum for the team and leaders to identify areas for improvement, set goals and implement programs to improve cross departmental collaboration and reduce inefficiencies. Provides topical updates to the Board of Directors and Medical Executive committee.

 

Identifies cases meeting the criteria for clinical case review through various sources. Performs preliminary (RN level) screening of retrospective review using indicators and screening criteria. Coordinates and communicates with physicians and clinical staff regarding screening and scoring of selected cases for peer review. Attends the medical staff peer review meetings and creates the records of the peer review discussion and outcomes. Coordinates follow-up planning process/activities. Coordinates quality- of- care Focused Professional Practice Evaluation (FPPE) activities on referral from Chief of Service. Assists in development and implementation of policies and procedures.

 

Leads survey readiness activities, including a reliable infrastructure for policies, regulatory compliance, and continuous improvement in demonstrating compliance. Works with regulatory agencies to ensure transparent communication of organizational changes and works with Facilities to ensure HCAI and CDPH compliance on all construction projects. Ensures that all organizational changes that need to be reported are reported.  Keeps current in new standards and advises key stakeholders of new requirements as appropriate.

 

Provide professional coaching including competency validation and consultation to influence leadership, physicians, direct care providers, and other stakeholders to deliver excellent pa