Director, Ambulatory Quality

At Memorial Hermann, we pursue a common goal of delivering high quality, efficient care while creating exceptional experiences for every member of our community. When we say every member of our community, that includes our employees. We know that when our employees feel cared for, heard and valued, they are inspired to create moments that exceed expectations, while prioritizing safety, compassion, personalization and efficiency. If you want to advance your career and contribute to our vision of creating healthier communities, now and for generations to come, we want you to be a part of our team.

Job Summary

The Director has primary oversight of the outpatient/ambulatory quality and patient safety program. This leadership role directs others within an outpatient setting in clinical robust process improvement supporting evidence based practices, the reduction of medical/health care errors and other factors that contribute to unintended adverse outcomes. The Director supports/leads robust process improvement ensuring high reliability methods, quality measures monitoring and ongoing regulatory compliance and readiness. The Director educates leadership, physicians, and staff on high reliability methodologies including system-based causes for medical error within the setting. The Director coordinates robust process improvement initiatives and projects within the area of oversight. The Director is responsible and accountable for optimizing quality and patient safety outcomes, while partnering with AVP Ambulatory Quality in defining the strategy for quality measurement and benchmarking for the area of responsibility. The Director works closely with operational leadership to optimize operational and strategic goals and objectives in line with quality priorities. The Director oversees the collection, analysis and reporting of quality, infection control and patient safety data within the area of responsibility in relation to cost containment, performance improvement and outcomes. The Director is accountable for facilitating, validating and reporting all improvement activities addressed at different levels including Monthly Operating Reviews and Quality Committees. The Director promotes interdisciplinary collaboration, fosters team work and champions service excellence. The Director serves as a resource and subject matter expert to proactively address quality and patient safety issues. Job Description Minimum Qualifications

Education: Bachelors Degree in Nursing, Pharmacy, orrelated clinical area required; Masters preferred

Licenses/Certifications: 

• Certified Professional Healthcare Quality (CPHQ), or Healthcare Accreditation Certifications Programs (HACP) Certification preferred

• Lean Six Sigma or Project Management Professional certification preferred

Experience / Knowledge / Skills:

• Five (5) years experience in hospital based nursing or clinical area required

• Two (2) years experience in post-acute, SNF, DME, or ambulatory required

• Two (2) years supervisory leadership experience required

• Two (2) years experience in quality and/or patient safety activities including regulatory compliance (TJC, CMS, and TDSHS) and quality measurement/improvement in the outpatient/post-acute or SNF required

• Two (2) years experience in robust process improvement methodologies or complete MHHS approved robust process improvement training within twelve months of employment

• Experience in statistical analysis or quantitative analysis

• Self motivated, proven communication skills, able to influence while being direct and succinct

• Background in business planning and targeted outcomes preferred

• Effective working relationships with Executives, Physicians, Directors, and staff

• Ability to serve as liaison to external regulatory and sanctioned reporting agencies

• Excellent written and verbal and presentation skills

• Knowledge of evidence based practice guidelines for clinical care and quality, and patient safety

• Ability to work collaboratively with Healthcare professionals at all levels to achieve established goals and improve quality outcomes

Principal Accountabilities

• Executes, integrates, and implements all components of quality and patient safety program.

• Identifies quality and patient safety improvement opportunities based on evidence based clinical practices and statistical analysis of current practice patterns.

• Oversees and manages clinical quality and patient safety data collection, aggregation, and dissemination within the designated area, specific to clinical quality and patient safety.

• Operationalizes implementation of area specific quality measurement programs required by external agencies like CMS, Rehab QRP, SNF QRP, MIPS and/or others as applicable within the area of oversight.

• Supports specialty accreditation as applicable within the area of oversight.

• Collaborates with system, regional and local leadership to establish and monitor outcomes measures within the outpatient setting.

• Leads, manages and promotes a culture of patient safety and implementation of high reliability practices within ambulatory setting.

• Collaborates with system and regional leadership to design, develop and implement patient safety alerts, prompts and tools within the ambulatory setting.

• Directs and manages local performance improvement and patient safety specialists in their daily quality and patient safety operations, and develops and implements systems for optimal knowledge transfer and efficiency within the setting.

• Refines and improves ambulatory processes to meet the anticipated needs and requirements of health care reform and One Memorial Hermann.

• Precepts, plans and directs short term and long term quality and patient safety robust process improvement projects to continuously improve the quality and patient safety program within the ambulatory setting.

• Directs and promotes communication and collaboration between all stakeholders in quality and patient safety strategies.

• Provides oversight in the use of data to drive decisions, to plan, to develop, and implement quality improvement strategies.

• Collaborates with system, regional and local leadership to establish the education program for physicians, managers, staff, patients and families pertaining to quality and patient safety principles.

• Oversees accreditation and regulatory continuous compliancewith TJC, CMS, MQSA and TDH.

• Directs and manages the day to day quality and patient safety operational budget.

• Assures that revenue, expenses, contribution margin and FTEs meet or exceed budget; prepares and submits budget and related reports; forecasts and accurately projects expenses; takes corrective action to address negative variances; identifies and proposes capital/budget items appropriately.

• Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.

• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.

• Demonstrates commitment to caring for every member of our community by creating compassionate and personalized experiences. Models Memorial Hermann’s service standards by providing safe, caring, personalized and efficient experiences to patients and colleagues.

• Other duties as assigned.

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