Director of Clinical Quality Improvement

Description

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DEPARTMENT SPECIFIC DUTIES:    
•    Oversee and provide direct input to the Performance Improvement Program.
•    Manages the measurements and reporting of public data bases.
•    Oversees the preparation of data for facility committees and Tenet quality reports.
•    Oversees the Patient Safety functions, including the Patient Safety Committee.
•    Ensure continuing compliance with all regulatory standards.
•    Oversee and provide guidance to the Infection Control Program.
•    Ensure risk/loss reduction through coordination and supervision of the Patient Relations program.
•    Identify physician practice patterns to reduce variable costs and Length of Stay for specific DRGs.
•    Collect and analyze data from various hospital information systems relating to procedural costs and lengths of stay.
•    Identify specific practitioners or medical staff departments with opportunities to reduce costs.
•    Present findings to individual physicians/medical departments with recommendations for possible alternatives in practice patterns.
•    Track cost savings; present findings to executive staff.
•    Plans, maintains, and monitors the departments’ financial resources to achieve operating goals for both facilities.         
•    Submits annual budget preparation plan by negotiated deadline annually.
•    Controls and monitors Labor Management costs to budgeted cost monthly; cost not exceeds flexed budgeted costs quarterly.
•    Ensures that current job standards/competencies exist for each member of the staff; ensures that criteria-based job standards/competencies are used as the performance evaluation is completed during the 90-day probationary period and annually: (Revises as necessary/reviews and updates annually.
•    Continually monitors the department’s activities and takes appropriate action to ensure efficient and effective operation; observes ongoing operations and analyzes performance to identify potential problems    
•    Coordinates attendance at Hospital Orientation for all new employees and facilitates and participates in department specific orientation for all new employees (if applicable).
•    Completes all Mandatory Continuing Education Requirements.
•    Meets with user departments on a routine basis to obtain feedback; document meetings and plan of action for improvement.
•    Maintain a good working rapport with all staff and other departments requiring frequent interactions and coordination efforts.
•    Communicates self and staff concerns and problems through proper written and verbal channels.
•    Communicates, cooperates and performs related duties with other members of hospital staff and administration in a courteous and efficient manner to achieve overall hospital goals and objectives.
 

Qualifications

Required:
        Master’s Degree in business, management or health related field
        10 years experience in health care with five years management experience
        Current California RN license
        Experience in improving organizational performance
        Experience in facilitating and leading multidisciplinary teams
        Experience in using the common statistical and non-statistical tools of process improvement
Strong written and verbal communication skills
Demonstrated ability to organize and work with groups of people
Ability to present data to professional groups and institute changes based on the data presented
Demonstrates problem solving and decision-making skills

Preferred: Experience in an acute health care setting as a practicing clinician

 

Tenet complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce. If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date. If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law.