Director of Quality

ABOUT US

Loretto Hospital is a safety-net hospital that serves more than 33,000 patients each year from Chicago's Austin and surrounding communities. Established in 1923 as a not-for-profit community-focused healthcare provider, Loretto offers its community a unique patient-centered healthcare delivery system that promotes general wellness and education. The hospital staff are committed to providing the best possible medical care in a holistic, safe and comfortable resident environment. By empowering patients with knowledge and resources, Loretto Hospital strives to cultivate a culture of proactive medical management within the community, with the goal of increasing the quality of life for patients and community residents.

SUMMARY
The Director of Quality is responsible and accountable for the Hospital's Performance Improvement and Regulatory Readiness programs. Supports Loretto Hospital's Mission and Vision statements by partnering with physicians, employees, and community to provide quality, patient-centered care while promoting wellness and education. Demonstrates the Loretto Values of Patient First, Teamwork, Excellence, Respect, Integrity, and Community Involvement.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Provides the leadership and strategic direction in developing the performance improvement program for the Medical Staff and Hospital Departments and/or Services
• Responsible for developing and implementing appropriate programs to assure the Hospital is compliant with regulatory regulations
• Works collaboratively with the Board of Directors, Medical Staff and Hospital Leadership to further advance performance improvement and regulatory readiness in the most effective and efficient manner.
• Collaborates with Medical Staff and Hospital Leadership, Hospital departments and/or services to implement the Hospital Performance Improvement Plan.
• Provides assistance to the Medical Staff, Hospital Departments and/or Services in the development of indicators, data collection and data analysis to assess and/or improve outcomes and compliance.
• Serves as primary contact for accrediting organizations such as the HFAP, IDPH and CMS.
• Stays current on regulatory requirements and communicates new and revised requirements to appropriate departments, services and staff. Provides guidance to staff in meeting compliance.
• Oversees the Hospital Tracer Program and performs tracer activities to assess hospital compliance to regulatory requirements.
• Performs other related duties as assigned.
  

COMPLIANCE RESPONSIBILITIES

• Understands and adheres to Loretto Hospital's compliance standards as they appear in the Compliance Policy, Code of Conduct and Conflict of Interest Policies
• Keeps abreast of all pertinent federal, state and Hospital regulations, laws, and policies as they presently exist and as they change or are modified.
• Ensures that the staff are trained and evaluated on their knowledge of and adherence to compliance policies and procedures specific to their jobs.

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of the personnel so classified. For purposes of the American with Disabilities Act, "Job Duties" are essential job functions.

JOB REQUIREMENTS

Required:

• RN or other clinical degree; current Illinois licensure as verified by the Illinois Division of Professional Regulation License Look-Up
• Knowledge in medical record and chart review and interpretation of care standards.
• Strong quantitative, analytical, organizational, problem solving and project management skills
• Ability to develop relationships with physicians, healthcare team members and other departments and/or external agencies. Basic computer skills.

Preferred:

• 3 years of experience in a clinical setting.

PHYSICAL DEMANDS

While performing the duties of this job, the employee is frequently required to sit, stand and walk as well as occasionally stoop, kneel, crouch or crawl. Using proper body mechanics, the employee may be expected to lift, pull, push or move patients and/or equipment.  Fine motor skills are required when using hands and fingers to handle, feel or reach.  Normal or corrected vision, hearing and ability to speak are necessary.  Specific vision abilities required include close vision, sharp eye focus and ability to distinguish colors.  There will be periods of stressful intense concentration with more than average pressure used in a variety of problem-solving situations.

WHY LORETTO

Competitive Compensation: Along with a competitive salary, Loretto Hospital offers a comprehensive, competitive benefits package including health, dental, vision, retirement savings plans, and paid time off.

Career Development: Loretto Hospital is a vibrant community of professionals dedicated to administering excellent patient care. Whether you are pursuing a career in allied health, support services, clinical or nursing support, or professional administration, Loretto Hospital is a tremendous place to grow as a health care professional.

Work Environment: As a not-for-profit, community-focused hospital, Loretto Hospital is truly a place where patients come first. We are seeking team members who not only support our mission, but who are customer service-driven and who desire to enhance the patient experience.