Director, Quality, Memorial & Regional Hospitals

About the Position

The Director of Quality reports to the Chief Quality Officer Beacon Health System and is responsible for leading coordinating and advancing quality patient safety regulatory readiness accreditation and performance improvement activities across assigned Beacon Health System entities including Memorial Hospital of South Bend Beacon Childrens Hospital Memorial Epworth Hospital Beacon Granger Hospital and Bremen Community Hospital.

This leader provides operational and strategic leadership for entity-based quality programs and serves as the primary quality leader supporting hospital executives medical staff leaders nursing leadership and clinical teams. The Director facilitates the planning implementation monitoring and evaluation of quality improvement strategies designed to improve clinical outcomes patient safety operational performance patient experience regulatory compliance and organizational reliability.

The Director serves as a change agent and advisor for leaders and teams throughout the organization and supports achievement of Beacon Health System strategic quality goals external quality rankings accreditation standards regulatory requirements and value-based performance objectives.

Essential Duties and Responsibilities

Establishes quality and patient safety direction for assigned Beacon Health System entities in accordance with organizational goals and objectives by:

• Determining short- and long-term quality patient safety regulatory and performance improvement objectives consistent with Beacon Health System priorities and assigned entity goals.
• Developing and executing strategic quality plans for Memorial Hospital of South Bend Beacon Childrens Hospital Memorial Epworth Hospital Beacon Granger Hospital and Bremen Community Hospital.
• Providing leadership guidance and accountability for entity-based quality management patient safety accreditation regulatory readiness and performance improvement activities.
• Promoting a culture of safety continuous improvement high reliability and accountability across assigned hospitals and associated business entities.
• Serving as the primary quality advisor to hospital presidents executive leadership nursing leadership physician leaders medical staff committees and department directors.
• Supporting system-wide standardization of quality and patient safety processes while addressing unique needs of the assigned entities including acute care childrens hospital inpatient behavioral health micro-hospital and critical access hospital environments.

Supervises develops and directs assigned Quality Management associates by:

• Conducting interviews and hiring qualified candidates for open budgeted positions.
• Establishing performance expectations and evaluating performance of assigned associates.
• Coaching mentoring and supporting professional development succession planning and bench strength for quality management associates.
• Counseling employees as necessary and interpreting Beacon Health System and departmental policies and procedures.
• Ensuring assigned team members have the skills tools and support necessary to provide effective quality safety regulatory and performance improvement services.

Coordinates Quality Management services with other departments and serves as a liaison for assigned entities by:

• Advising the Chief Quality Officer regarding entity quality status priorities risks resource needs and opportunities for improvement.
• Participating in department directors meetings hospital leadership meetings medical staff committees quality committees system committees and other meetings as assigned.
• Establishing and maintaining effective communication and working relationships with medical staff hospital presidents nursing leadership operational leaders department directors and other Beacon Health System leaders.
• Supporting medical staff quality committee activities performance improvement presentations and quality monitoring results as needed.
• Serving as a quality liaison to system committees requiring quality outcome data regulatory information performance improvement support or patient safety expertise.
• Coordinating or initiating correspondence action plans and quality improvement plans with regulatory bodies payers and outside agencies as assigned.

Enhances quality outcomes and patient safety by:

• Leading or participating in improvement work in patient safety clinical quality patient experience regulatory compliance and clinical operations.
• Utilizing and sharing high reliability and performance improvement tools methods and approaches with leaders physicians and teams.
• Facilitating projects workshops and interdisciplinary teams to support improvement in outcomes and sustainment of gains.
• Serving as a change agent in efforts for quality safety and operational improvement.
• Ensuring compliance with external and internal regulatory requirements related to accreditation licensure quality reporting and patient safety.
• Interpreting disseminating and communicating trends in quality and safety data to leaders departments medical staff and associates.
• Explaining the meaning of process and outcome data and how performance reflects success in quality improvement and patient safety initiatives.
• Identifying implementing and monitoring action plans to address opportunities for improvement.
• Supporting development monitoring and presentation of quality scorecards dashboards board reports and regulatory submissions.
• Promoting a culture of safety and supporting patient safety culture survey analysis and action planning.
• Helping develop project plans and facilitating improvement in risk reduction initiatives.
• Overseeing event trend review quality and patient safety action plans and communication of patient safety concerns to practices and leadership as appropriate.
• Responding to serious safety events and supporting root cause analyses apparent cause analyses failure mode and effects analyses and other investigative activities.
• Responsible for the growth in use of high reliability strategies and performance improvement methods across assigned entities.
• Responsible for the creation review revision and communication of clinical quality and safety-related policies as assigned.

Supports regulatory accreditation and external performance expectations by:

• Leading readiness activities for The Joint Commission CMS Indiana Department of Health Michigan Department of Health and Human Services and other regulatory agencies as applicable.
• Supporting improvement related to publicly reported quality measures patient safety indicators value-based purchasing Leapfrog Vizient CMS Stars and other external performance programs as assigned.
• Collaborating with Infection Prevention Risk Management Clinical Documentation Integrity Analytics Nursing Medical Staff Services and Operations to improve outcomes and sustain regulatory compliance.
• Ensuring accurate timely and actionable quality data are available to leaders for performance monitoring decision making and corrective action planning.

Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department by:

• Acting as a quality patient safety regulatory and performance improvement resource to other department members and organizational leaders.
• Remaining current in leading practices regulatory requirements accreditation standards quality
• methodologies and healthcare performance improvement strategies.
• Completing other job-related assignments and special projects as directed.

Ideal Candidate Characteristics

Education and Experience

• Bachelors degree in nursing healthcare administration public health business administration or other healthcare-related field required.
• Masters degree in nursing healthcare administration public health business administration or other healthcare-related field preferred.
• Minimum of seven years of progressive healthcare quality patient safety regulatory accreditation or performance improvement experience required.
• Minimum of three years of leadership experience required.
• Experience leading quality and patient safety programs within an acute care hospital environment required.
• Experience with The Joint Commission CMS Conditions of Participation state regulatory requirements accreditation standards and value-based purchasing programs required.
• Knowledge and experience in quality improvement models such as Lean/Six Sigma the IHI Model for improvement high reliability or other comparable performance improvement strategies required.
• Experience in root cause analysis apparent cause analysis Healthcare Failure Mode and Effects Analysis serious safety event review and corrective action planning preferred.
• Certification in Healthcare Quality (CPHQ) Patient Safety (CPPS) Lean Six Sigma or equivalent preferred.

Leadership Competencies

• Drives Results - Consistently achieving results even under tough circumstances.
• Customer Focus - Building strong customer relationships and delivering customer-centric solutions.
• Instills Trust - Gaining the confidence and trust of others through honesty integrity and authenticity.
• Collaborates - Building partnerships and working collaboratively with others to meet shared objectives.
• Communicates Effectively - Developing and delivering multi-mode communications that convey a clear understanding of the unique needs of different audiences.

Knowledge & Skills

• Demonstrates administrative and supervisory skills necessary to direct organization programs and supervise professional and paraprofessional staff.
• Demonstrates analytical skills necessary to develop programs evaluate projects monitor outcomes and recommend changes in policies procedures and resource allocation.
• Demonstrates accurate and thorough data collection analysis interpretation and communication skills.
• Demonstrates knowledge of healthcare quality management patient safety science regulatory and accreditation standards and performance improvement methodologies.
• Demonstrates knowledge of national standards and outcomes for quality safety publicly reported measures value-based purchasing AHRQ Leapfrog CMS Vizient and other benchmarking or external performance programs.
• Demonstrates interpersonal skills necessary to interact effectively with a variety of contacts within and outside the organization including medical staff hospital executives nursing leadership department directors external regulatory agencies and community partners.
• Demonstrates well-developed communication skills both verbal and written.
• Demonstrates ability to make effective presentations before groups of various sizes.
• Demonstrates initiative judgment creativity leadership ability and sound decision making.
• Demonstrates consultative team building facilitation change management and project management skills.
• Demonstrates ability to network influence and lead multidisciplinary teams without direct authority.
• Must work well under pressure and be able to meet changing priorities and deadlines.
• Must be able to work well with staff leaders and medical staff at every level within the organization

Required Experience:

Director