Director of Clinical Quality Improvement

Description

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SPECIFIC DUTIES:   

• Oversight of organizational improvements and quality measures for the entire facility. The DCQI will oversee the development and measuring of various clinical quality metrics, and quality improvement initiatives.
• Collaboration and partnership with Medical Staff, department chiefs and chairs, A-Team members, Department Directors and leaders, and the Tenet Corporate teams to plan, program and oversee quality and safety programs smoothly and effectively.
• Partners closely with CMO, CNO and physician leaders and associates to enhance care, improve quality and safety, advance patient, and family satisfaction, maintain compliance, and reinforce a culture of high performance and elevated levels of provider and staff engagement.
• Works directly with directors and managers to educate to quality improvement and safety processes. Assists in the development of quality and safety action plans. Oversees process improvement data from directors to ensure compliance. 
• Translate Corporate, national/state, and local quality and patient safety programs into clear objectives and action plans. Coordinate alignment of strategic quality goals associated with performance metrics across DRMC.
• Implementation of quality improvement measures to improve performance and ensure compliance with JCAHO, HIPPAA and other state and federal regulations.
• Provide key leadership towards patient safety, clinical analytics, informatics, and quality programs to meet established patient safety, quality, and compliance goals.
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• Supports efforts to ensure an exceptional patient experience and participates in the management of patient grievances and quality of care issues. 
• Leads hospital clinical quality and safety analytics programs. Responsible for providing hospital and Medical Staff Leadership the performance results of safety and quality initiatives. Serves as member Medical Staff Executive Committee and provides linkage between DRMC quality initiatives and quality and patient safety initiatives.
• Works in collaboration with Directors to address quality and safety opportunities across the organization. Active engagement in the development of the organizational culture of safety. 
• Collaborate with the Chief Nursing Officer (CNO) for synergistic nursing practice safety and quality program alignment within the activities of the medical staff. Works to support and advance service excellence strategies.
• Leads performance improvement/continuous improvement initiatives in the hospital. Integrate and prioritize resources to maximize impact across all hospital areas. 
  Co-Chairs the Quality Committee.
• Participates in the annual Hospital Education Plan, annual competency process, and new employee orientation process.
• Oversee the Infection Prevention Program in collaboration with the Infection Prevention Medical Director.
• Provides administrative oversight of the Medical Staff Peer Review process in collaboration with Medical Staff leadership.
• Collaborates with risk management functions for the medical center and works in collaboration with the Patient Safety Officer.
• Oversee the policy and procedure process for the medical center, ensuring all policies are current, meeting regulatory compliance, and support evidence-based guidelines.
• Maintains a high-performance work environment characterized by quality performance, positive relationships, and a dedicated team orientation to achieve performance targets and model the standards of behavior.
• Collaborates with the Emergency Management processes at the hospital and across the Network.
• Other duties as assigned.

Qualifications

Required:

• CPHQ certification or Equivalent
• Experience in an acute health care setting as a practicing clinician
• 10 years’ experience in health care with five years management experience
• Demonstrated ability to implement processes to improve patient safety
• Experience in improving organizational performance methods
• 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
• Current knowledge of Joint Commission, state, and federal guidelines, regulations, and standards, having prepared, and participated in state, Joint Commission, and CMS surveys within past 3 years.
• Experience with CMS conditions of participation for acute care hospitals and CMS and Joint Commission survey processes.
• In-depth knowledge of external clinical quality reporting requirements

Preferred:        

1. CPHRM
2. Master’s degree in business, management or health related field
3. Experience with CDPH surveys within the past 5 years.   

 

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.