The Director of Quality and Performance Improvement

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. Thats 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.

Develops and presents quality improvement reports to the various Hospital and Medical Staff committees and assists in their preparation for Board meeting presentations. Manages medical staff Ongoing Professional Practice Evaluation (OPPE), Focused Professional Practice Evaluation (FPPE), and peer review program and assures consistent application across sites and disciplines.

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.

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Responsible for leading the organizations 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 Hospitals 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 Hospitals 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 high-performance teams by supporting the development of departmental goals and metrics, ensuring they are used to motivate staff and performance.

Education and Work Experience:

Bachelors degree in healthcare related field required, masters degree in health-related field or MBA preferred.

Minimum five years experience in quality, safety, regulatory compliance, and/or operations improvement; five years of management experience which includes as a director or manager in directing projects and teams.

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Knowledge and Skills:

Experience Preferred in EPIC and MEDITECH software systems.

Demonstrated knowledge of quality improvement principles and practices (i.e., rapid cycle improvement, Six Sigma, Lean, balanced scorecards, etc.), project management, patient safety concepts, data analysis, data management, and statistical process control in healthcare.

Proficient computer skills with extensive experience using various software applications such as MS Excel, Word, Access, PowerPoint; relational database structures, and reporting software.

Experience with clinical/healthcare software applications preferred; demonstrated knowledge and skills in statistical packages and concepts including control charts.

High-level skill in the use of complex data in business/value development and the ability to analyze data and draw meaningful conclusions.

Demonstrated ability to manage projects involving large volumes of data; ability to instruct others effectively; display, analyze, package, and explain data to individuals with varied levels of understanding and abilities; and experience with healthcare collaborative measures across a health system.

Strong strategic analytical skills for data, product line, and continuum of care analysis.

Excellent oral, written, platform and interpersonal communication skills. Ability to work independently.

High degree of creativity in problem-solving.

Certifications/Licenses:

Six Sigma, Lean, Certified Professional in Patient Safety (CPPS), and/or Certified Professional in Healthcare Quality (CPHQ) certification desired.

Benefits:

Sinai Health Systems goal is to provide you with the most comprehensive benefit package possible while balancing our fiscal commitments and obligations. Sinai Health Systems currently offers its employees the option to participate in a full range of benefits, including a health care program which includes medical, dental, vision and prescription coverage. Along with Employer Paid Life and Accidental Death & Dismemberment (AD&D), Supplemental Life, Short-Term and Long-Term Disability, Health Savings Account (HSA) and Flexible Spending Account (FSA), Employee Assistance Program and Student Loan Assistance. Participation in some programs requires that employees be regularly scheduled to work a minimum number of hours and/or to have fulfilled a waiting period after they begin employment with Sinai Health Systems.

Living the Values:

TEAMWORK - Caregiver works together with other caregivers to create and maintain an inclusive workplace where differences, inclusivity, conflict resolution and open communication are valued

RESPECT - Caregiver shows mutual respect and fairness, treats each person with dignity and encourages each individuals unique talents and contributions

QUALITY - Caregiver improves our services by following protocol and suggesting improvements based on observations, continuous learning and industry best practices

INTEGRITY - Caregiver holds self and others accountable for their actions and are honest and ethical in all dealings

SAFETY - Caregiver practices behaviors that promote safety for all patients, visitors, and caregivers

ROLE MODEL - Caregiver is a dependable role model and champions our values through their daily interactions with patients, customers and coworkers.