Directs development and implementation of quality management strategies, programs and regulatory compliance. Actively collaborates with physician services, nursing, other allied health professionals, ancillary and support personnel, and operational leadership to promote implementation of evidence-based quality and patient safety initiatives, and to engage Associates at all levels as participants in a continual pursuit of improvement opportunities. Establishes and maintains efficient and reliable mechanisms for monitoring, analysis and reporting of quality outcomes and process improvement initiatives, in alignment with regulatory standards and healthcare best practices for quality and patient safety. Promotes and vigorously supports a comprehensive culture of quality throughout the organization, across all regions, campuses, and departments.
CHRISTUS COMPETENCIES FOR MANAGERS AND DIRECTORS
Drives results- Consistently achieving results, even under tough circumstances.
Manages conflict- Handling conflict situations effectively, with a minimum of noise.
Communicates effectively- Developing and delivering multi-mode communications that convey a clear understanding of the unique needs of different audiences.
Directs work- Providing direction, delegating, and removing obstacles to get work done.
Builds effective teams- Building strong-identity teams that apply their diverse skills and perspectives to achieve common goals.
Business insight- Applying knowledge of business and the marketplace to advance the organization's goals.
Ensures accountability- Holding self and others accountable to meet commitments.
· Directs the overall development, implementation, and integration of various regulatory, quality, patient safety, and other hospital improvement programs, using a systematic approach to monitoring the effectiveness of the program including problem resolution strategies
· Responsible for coordinating the overall development, implementation, and integration of the Quality Management System with other improvement programs within the organization
· Identifies and ensures compliance with all regulatory standards related to accurate and timely aggregation and reporting of quality outcome measures to appropriate internal and external stakeholders and agencies
· Directs department staff to promote an organization-wide focus on achieving optimum clinical and operational outcomes by utilizing an organized, structured approach to continuous improvement using risk based corrective action plans
· Promotes high reliability organization fundamentals to reduce errors.
· Develops, facilitates and coaches leadership on policy and procedure to direct processes within the organization
POSITION SPECIFIC COMPETENCIES
· Directs the activities of the quality management teams, administers process improvement initiatives, and directs the evaluation, interpretation and documentation of the improvements.
· Must have knowledge of all clinical quality and testing procedures as well as ensure that the clinical quality department budget is met.
· Involvement with processes for measuring, reporting and improving various quality programs such as Patient Satisfaction and Patient Safety, Medical Staff privileging and peer review, accreditation and TJC assessments and collaboration with groups responsible for outcomes across the continuum of care
· Bachelors in Healthcare Administration, Nursing or a relevant clinical discipline required, with evidence of additional training in PI and Quality
· Master's degree preferred
· CPHQ ( Certified Professional in Healthcare Quality) or similar certification in quality, preferred
· Minimum of five (5) years clinical experience in a hospital setting, including progressive management responsibilities
· Two (2) to three (3) years Quality Improvement experience in acute care hospital
· Experience with managing organizational change, regulatory compliance, process improvement activities and quality management
· Comprehensive knowledge of Nursing and health care practices and techniques.
Licenses, Registrations, or Certifications
· RN license in good standing in state of employment or a compact state, if applicable
· CHRISTUS Health System approved Basic Life Support certification
· Current Certified Professional in Healthcare Quality (CPHQ), or similar quality certification. If not current, then obtained within 2 years
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.