Director of Quality

4 weeks ago

Chicago, United States Sinai Chicago Full time

About Us:
At Sinai Chicago, we take health care personally. Excellence in health care is about more than just medicine, technology, tests and treatments, it is about really caring for people with dignity and respect. That’s what we do. We are dedicated to providing the best care to meet the needs of people, for our community, for our patients and for you.

Position Purpose:
The Director of Quality and Performance Improvement is the system leader accountable for driving continuous improvement, reducing care variation, elevating quality and clinical excellence, and care transformation. This includes minimizing financial risk related to pay-for-performance programs, ensuring the best outcomes to strengthen the Sinai Health System brand, developing and leading strategies for implementation, evaluation, and sustainment that support the elimination of risk and harm to patients, improvement in the quality and experience of care delivery and transformation. This position works to eliminate preventable harm, attain unsurpassed clinical and patient-reported outcomes, and build hospital-wide participation through transparency, collaboration, and mutual learning. Working in partnership with senior administrative and medical staff leadership, this position oversees the institutional approach to care transformation and leads a comprehensive quality/performance improvement program.

Key Job Activities:

- Monitors, reports, and improves the activities related to ensuring the best patient outcomes and the highest value of care and help lead the organization to attain the highest publicly reported rankings in Centers for Medicare & Medicaid Services (CMS) Hospital Compare, Leapfrog, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), Value-Based Purchasing, Meaningful Use, and others.
- Ensures timely compliance with quality analytics measure reporting to avoid penalties.
- Champions work efforts around safety and zero harm across all parts of the care continuum and partners with leadership to lead zero harm improvements.
- Educates and trains leadership, staff, and physicians as to the quality performance improvement program and their respective responsibilities in carrying out the program.
- Leads quality and performance improvement efforts to align strategic priorities, interventions, and standard work to harmonize system-wide approaches where appropriate.

sinaichicago.org
- Responsible for leading the organization’s drive to achieve and maintain top decile performance as measured by Leapfrog, Value-Based Purchasing, CMS, and other publicly reported methodologies.
- Collaborates with various members of the Hospital’s global quality team. (i.e., Transformational Care, Nursing, Environment of Care, Ancillary Operations, Ambulatory Care, Outpatient, etc.) and assists with the planning and execution of the Hospital’s quality strategic plan.
- Develops, implements, manages, and achieves annual Quality and Patient Safety Plans in collaboration with department director and unit leaders.
- Develops, plans, and executes department improvement projects. Ensures consistent practices throughout all phases of the quality improvement project life cycle. Drives the development and manages the execution of high-quality, integrated cross-functional plans for projects. Applies project management best practices (relevant statistical tools, and associated methodologies [Root Cause Analysis (RCA), Failure Mode and Effects Analysis (FMEA), Define, Measure, Analyze, Improve and Control (DMAIC)].
- Leads efforts to maintain continuous compliance with all regulatory and accreditation requirements from agencies including CMS, The Joint Commission (TJC), Accreditation Commission for Health Care (ACHC), and Illinois Department of Public Health (IDPH).
- Oversees monitoring of accreditation and regulatory performance and provides results to Sinai Leadership, making recommendations for appropriate corrective action.
- Oversees development, implementation, and tracking of corrective action plans to eliminate non-compliance.
- Responsible for leading and co-chairing the Hospital Quality Improvement Committee (HQIC) and provides oversight for all department quality committees.
- Supports improved quality compliance by educating clinical and ancillary staff on quality methodology. Serves as a resource to staff on potentially problematic and complex cases.
- Implements, facilitates, and advances the work of quality committees and quality plans. Sets and achieves appropriate goals for quality and performance improvement. Directs improvement initiatives and transformation activities.
- Works with all leaders and teammates to ensure a patient-centered culture of respect, learning, and continuous improvement.
- Serves as a leader for Lean Strategy development the deployment of Lean methodology change management and problem solving.
- Provides coaching and career development to staff, ensuring high morale and commitment. Leads h

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