Job Description

Under the direction of the Vice President and Chief Quality Officer, the Director of Quality Improvement is responsible for developing and implementing the organization’s Performance Improvement plan and priorities consistent with regulatory standards and evidence based best practices. As a member of the leadership team, serves as a role model and leader to colleagues and staff throughout the organization. Thoughtfully develops and implements initiatives to achieve improvements consistent with hospital strategic priorities. Promotes a culture that is positive, that values individual strengths, and is committed to optimal patient care, and compliance with regulatory standards. This position is responsible for direct supervision of the Quality Analyst and Quality Improvement Specialist and serves as the Stroke Coordinator.

Key responsibilities include:

• Strategic focus on improving quality. Responsible for goal setting and achievement using SJMC established Performance Improvement methodology and analytic tools. Defines measurable and actionable metrics and ongoing monitors to sustain performance.

• Identifies and drives analytic needs for improvement projects/initiatives. Supports leaders in development of problem charter and selection of the best tools for data analysis. Mastery of basic statistical concepts, tools and techniques and working knowledge of improvement tools and techniques. Teaches/mentors others on basic topics and able to assist others with advanced topics.

• Serves as Stroke Coordinator and supports the Stroke Program including defining and developing structure, process and outcome measures, policies, accreditation and facilitating and actively developing initiatives to meet and exceed evidence-based care metrics for stroke patients.

• Lead and/or facilitate complex multidisciplinary improvement teams as needed to achieve quality and performance improvement goals.

• Responsible for oversight of data collection, measurement, and data analysis for organizational, federal and state quality metrics.

• Coordinate mortality, patient complaint, and outcome reviews.

• Serve as a regulatory resource regarding state and federal regulations and standards, including but not limited to CMS, TJC, and NYS.

• Create and present data needed for evaluation and appropriate action by committees, leadership, and quality improvement teams.

• Represents the organization within and external to the community when required.

• Assist in improving patient experience through analysis of data and implementation of initiatives to improve performance.

Requirements:

• Bachelor’s Degree or commensurate experience required.

• Registered Nurse in New York State required

• Master’s Degree in Healthcare specialty preferred

• Current certification as CPHQ strongly preferred. Certification required within 3 years of hire date.

• Previous managerial experience preferred.

• Competence in Microsoft office products including PowerPoint and Microsoft Excel.

• Familiarity with health care clinical operations and processes in an acute care hospital setting.

• Familiarity with regulatory requirements as related to hospital setting.

Other Requirements:

• The employee must regularly lift, carry or push/pull less than 10 pounds, frequently lift, carry or push/pull less than 10 pounds, and occasionally lift, carry or push/pull up to 10 pounds.

• While performing the duties of this Job, the employee is regularly required to perform activities that require fine motor skills. The employee is frequently required to do repetitive motion, hear, reach, sit, and speak. The employee is occasionally required to walk.

• Specific vision abilities required by this job include color vision, far vision, and near vision.

• The noise level in the work environment is usually quiet.

Salary: $170K-$180K

Saint Joseph's Medical Center is an equal opportunity employer.

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