Director Quality Management III - Quality Management

Summary:

In a High-Reliability Organization, the Director Quality is responsible for the overall operations of the quality management program throughout the hospitals. The quality management program consists of quality, risk management, infection prevention, and safety. Acts as a resource to members of the management team in reference to guidelines for quality and safe patient care. Identify and report patient safety risk trends. Collaborates with key stakeholders to analyze patient safety risks and events. Implements action plans to mitigate safety risks. Utilizes and integrates data from internal and external sources to drive performance improvement using validated change management tools. Collaborates with leadership and clinicians to improve patient care quality and safety using trended data and action plans. Operationalizes processes to support standards compliance for regulatory bodies. Facilitates and guides the organization through continuous survey readiness activities and drives action plans to meet compliance. Ensures that the facilities' policies and practices, as related to patient care, are within best practice guidelines and standards, as designated by all State and Federal agencies as well as certifying agencies.

The Director Quality Management III is responsible for the overall operations of quality management programs throughout Type C (Tertiary Care defined as a level above Secondary health care that includes highly specialized medical care that involves advanced and complex diagnostics, procedures, and treatments performed by medical specialists in state-of-the-art facilities) hospital facilities.

CHRISTUS Santa Rosa Hospital - San Marcos, which originated in 1923 as Hays County Soldiers, Sailors and Marines Memorial Hospital, opened at its current Wonder World Drive location in 1983. Our staff of more than 700 Associates works with more than 300 active and consulting physicians to provide quality services to patients and their families. For more than 20 consecutive years, we have been named The Best Hospital in Hays County in the annual "Best of Hays" publication released by the San Marcos Daily Record. In addition to interventional cardiac services, CHRISTUS Santa Rosa Hospital - San Marcos is a Certified Chest Pain Center and an accredited Primary Stroke Center. We lead the region in da Vinci robotic-assisted surgery and offers a variety of specialty care services including medical imaging, rehabilitation, hospice, women's services and more.

Responsibilities:

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Communicate effectively to different audiences.
• Proficient in computer skills using EXCEL, PowerPoint, MS Office, and Flowchart tools.
• Knowledgeable on High-Reliability Principles and PDSA methodology.
• Knowledgeable on payment models for quality metric performance.

Source: NAHQ Workforce Accelerator Competency Framework 2022: Eight Domains

• Quality Leadership and Integration-Advance the organization's commitment to health care quality through collaboration, learning opportunities and communication. Lead the integration of quality into the fabric of the organization through a coordinated infrastructure to achieve organizational objectives. Domain Level: Advanced.
• Performance and Process Improvement-Use performance and process improvement (PPI), project management and change management methods to support operational and clinical quality initiatives, improved performance and achieve organizational goals. Domain Level: Advanced.
• Population Health and Care Transitions-Evaluates and improve health care processes and care transitions to advance the efficient, effective, and safe care of defined populations. Domain Level: Proficient.
• Health Data and Analytics- Leverage the organizations analytic environment to help guide data-driven decision-making and inform quality improvement initiatives. Domain Level: Advanced.
• Regulatory and Accreditation-Direct organization wide processes for evaluating, monitoring, and improving compliance with internal and external requirements. Lead the organization's processes to prepare for, participate in, and follow up on regulatory, accreditation, and certification surveys and activities. Domain Level: Advanced.
• Patients Safety-Cultivate a safe healthcare environment by promoting safe practices, nurturing a just culture, and improving processes that detect, mitigate, or prevent harm. Domain Level: Advanced.
• Quality Review and Accountability-Direct activities that support compliance with organization-wide voluntary, mandatory, and contractual requirements for data acquisition, analysis, reporting, and improvement. Domain Level: Advanced.
• Professional Engagement-Engage in the healthcare quality profession with a commitment to practicing ethically, enhancing one's competence, and advancing the field. Domain Level: Proficient.

Job Requirements:

Education/Skills

• Bachelor's degree of Science in Nursing or other related field required.
  

• Master's degree preferred.

  
  

Experience

• Five years of healthcare experience.
  
• Two years of management experience.
  

• Three years of quality management experience.

  
  

Licenses, Registrations, or Certifications

• CPHQ (Certified Professional in Healthcare Quality) required or within 1 year of hire.

Work Schedule:

Varies

Work Type:

Full Time