Director Quality SJMC-SCH

2 weeks ago

Tacoma, Washington, United States CommonSpirit Health Full time

Overview:


In 2020 united in a fierce commitment to deliver the highest quality care and exceptional patient experience Virginia Mason and CHI Franciscan Health came together as natural partners to build a new health system centered around the patient: Virginia Mason Franciscan Health.

Our combined system builds upon the scale and expertise of our nearly 300 sites of care including 11 hospitals and nearly 5000 physicians and providers.

Together we are empowered to make an even greater impact on the health and well-being of our communities.

Responsibilities:


This position is responsible for the design, coordination, implementation and management of the Performance Improvement (PI) plan and identifies opportunities for improved patient care, incorporate evidence-based practices, and improved patient outcomes.

Provides leadership in defining, implementing and integrating quality, safety, service and efficiency strategies into the plans, policies, and organizational processes that affect the organizations operations and strategic direction.


ESSENTIAL KEY JOB RESPONSIBILITIES:


Establishes performance improvement goals annually with relevant stakeholders, ensures that the PI plan and the hospital-focused projects for the year are implemented and effectiveness evaluated annually.

Facilitates a multidisciplinary approach to performance improvement and fosters participation in all performance improvement initiatives to share and learn best practices.

Develops and implements processes and formats that support data collection, aggregation, analysis, and action planning. Assures data is managed appropriately and disseminated to appropriate leadership staff.


Provides leadership in developing quality improvement training programs and coaches organizational clinical/service lines and operational/support departments in quality improvement principles.


Collaborates with the Medical Staff and Organizational Leadership to develop and enhance safe patient care while achieving optimal outcomes, including the organizations peer review program and ongoing and focused practitioner evaluation.

Ensures compliance and provides leadership and oversight for accreditation, licensure and regulatory survey readiness.

This includes mock survey tracers to assess survey readiness, education to staff and providers on regulatory compliance and identification for areas of opportunities and the corresponding actions for compliance at the facility level.

Organizes
required staff to develop responses to survey deficiencies and oversees response submissions to the appropriate accreditation or regulatory agency.

Has overall accountability for assigned work group relative to operational goals, personnel requirements, and budgetary constraints.

Qualifications:


Bachelor's degree in a healthcare-related field or five (5) years of related job or industry experience in lieu of a degree.

Minimum of five (5) years of progressive management responsibility in a health care setting, two (2) of which is related to managing an acute care organizations Quality Improvement Program.

Minimum of two (2) years of clinical, patient care experience or equivalent.
Current State License in a clinical field. Five (5) years experience in Quality Management can be used in lieu of state license.

Certified Professional in Healthcare Quality (CPHQ), or Healthcare Quality and Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment is required.

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