Responsible for the overall direction of the operations of the Department of Quality Review; includes responsibility for direction of fiscal and human resources required to support this department and the development of the quality review coordinators.  This position requires excellent and persuasive communication skills, including written, verbal, and active listening skills; strong interpersonal skills; and proven ability to influence others across organizational and functional line.

Extensive clinical experience is required, as credibility with all levels of providers is essential, as is detail level understanding of clinical workflow and throughput, and the ability to speak the same language as all individuals involved with case or event review.

This position requires frequent preparation of highly detailed and/or confidential reports, and the development and ongoing revision of policies, procedures, and other guidance documents that are used by others at all levels of the organization.

Essential Function:

Oversee investigation and root cause analysis of all hospital incidents, including the implementation of improvements identified utilizing evidence based, data-driven decision making to drive process and cultural change.

Direct the daily activities of the Quality Team including:

1. Completion of analysis of individual patient quality issues identified through screening or referral.

2. Leading teams through conduction of root cause analyses.

3. Facilitating and leading interdisciplinary teams in the development of performance improvement strategies in response to identified risks and opportunities.

4. Managing the process involved in team selection, facilitation, event and/or process analysis, and risk reduction strategy development to achieve organizational performance improvement.

5. Developing systems for systematic monitoring and analysis of outcomes of patient care processes.

Coordinates and facilitates the activities of the Quality Review Committee.  Directs the preparation of reports and case summaries.  Maintains interface with leadership members of the Quality Services Division, Risk Management and other areas as needed to reduce duplication of work.

Guide the process involved in RCA team selection, facilitation, event and/or process analysis, failure mode effects analysis (FMEA) and risk reduction strategy development to achieve organizational performance improvement.

Develop systematic monitoring and analysis of outcomes/trends of patient care processes that promote sustainable change.

Aggregate and analyze findings from multiple sources (incident reporting system, grievance reporting, quality indicator system, etc.) to identify system opportunities to improve patient safety.

Create and maintain internal and external benchmarks for Quality Review and improvement:

- Develop metrics that allow internal benchmarking for quality initiatives within organization

- Maintain and present monthly metrics to interested committees or parties

- Participate in the CHCA PSO program, coordinating provision of internal quality data for external benchmarking as it relates to patient safety activities.

Communicate with directors, managers, staff, and physicians on expectations/problems/deadlines relating to quality, strategic initiatives, regulatory issues, and all other relevant communications of the organization.  Requires communicating clearly and with key issues/goals/objectives at the center of the communication.

Position Requirements:

Minimum 5-7 years of related experience

Previous quality management/improvement, risk management and/or performance improvement

Four-year Bachelor's degree or equivalent experience;

Graduate or professional work or advanced degree; or equivalent experience

Registered Nurse, RN: required

Specific Knowledge, Skills and Abilities:

Experience in leading/facilitating multidisciplinary teams

Experience in data and performance improvement analysis

Experience in conflict management

Licenses and Certifications:

Certified Professional in Healthcare Quality, CPHQ :preferred

Registered Nurse, RN: required

Skills and Certifications

CPHQ

Registered Nurse

Description of the Ideal Candidate

The ideal candidate has been a Director of Quality, Quality Review, Quality Managment, Improvement, Risk Managment or Performace Improvment but must be a registered nurse. The candidate would have their CPHQ along with the Director experience in a large pediatric hospital for at least 3+ years. Someone with conflict resolution experince, has developed a robust quality process previously, has a graduate degree, has experience with FMEA and has overseen RCA activities.