SUMMARY:

Develops, coordinates, and directs the implementation of the Quality Performance Program.  Leads the Performance Improvement (PI) program and communicates quality and PI activities throughout the organization.  Is responsible for the design, implementation, and on-going maintenance of quality programs. 

 

ESSENTIAL FUNCTIONS:

Participates in organizational quality planning and takes ownership of implementation of strategic activities that fall within quality domains.

Ensures organizational alignment with TMC’s quality standards.

Provides expert guidance and support to the organization by working with the quality team to identify opportunities for competency development and performance improvement and achieves improvement results.

Areas of responsibility include quality, abstractors, quality analysts, and PI. 

Oversees PI activities.  Assists with or facilitates activities to continuously improve quality and operation performance within TMC Healthcare.

Develops an overarching PI strategy and collaborates with leaders and staff in the implementation of this strategy.

Effectively manages staff; interviews, hires and trains; evaluates employee performance; addresses performance problems as appropriate; delegates work assignments effectively.

Oversees assigned budgets, including projections and reconciliation; understands implications of TMC business decisions on bottom line and manages activities to produce results to support business decisions.

Adheres to and supports team members in exhibiting TMCH values of integrity, community, compassion, and dedication. 

Adheres to TMCH organizational and department-specific safety and confidentiality policies and standards.

Performs related duties as assigned.

 

MINIMUM QUALIFICATIONS

 

EDUCATION:  Bachelor’s degree required. Master’s degree preferred.

 

EXPERIENCE:  Seven (7) to ten (10) years of quality experience or demonstrated clinical/quality improvement results in an acute care setting.  

 

LICENSURE OR CERTIFICATION: Certified Professional in Healthcare Quality (CPHQ) required.  Certification or advanced training in PI tools is preferred.

 

KNOWLEDGE, SKILLS AND ABILITIES:

• Comprehensive knowledge of health care operations, recognizing the uniqueness of the healthcare environment.
• Advance knowledge in Quality including Joint Commission and CMS regulatory requirements, HCAHPS and pay for performance requirements, knowledge of quality tools such as Root Cause Analysis and Kaizen and knowledge of reporting requirements and systems.
• Ability to develop, coordinate, implement and evaluate the effectiveness of quality programs and process excellence for the health care system.
• Well-developed project management, process redesign, and analytical skills.
• Leadership experience overseeing progressively complex projects and interfacing with executive leaders.
• Demonstrated proficiency to identify and articulate quality and process improvement opportunities and provide consultation to leadership. 
• Excellent communication skills to interact with physicians, patients/ family, community health care system staff and external reviewers.
• Ability to motivate others to drive change and ability to communicate respectfully and collaboratively around improvement opportunities.
• Comfortable operating in a collaborative, shared leadership environment.

Demonstrated ability to effectively establish and maintain working relationships with peers at all levels of the organization