About the position
Under the leadership of a vice president, the department director carries out the strategy and vision for the assigned departments (including Quality Management, Medical Staff Services, Infection Prevention) that supports Community Hospital's strategic plan, quality commitment, and values while complying with hospital policies/procedures and applicable laws and standards. The director is responsible and accountable for overall management of the assigned departments and service to include assessing, planning, implementing, and evaluating all aspects of care/services delivered; ensuring quality programs, patient safety, and a level of customer service that strives to exceed internal and external customer expectations. The director develops and mentors a high-performing team for all areas of responsibility through practice of excellent employee relations, attention to employee needs (including fostering effective working relationships training, developing/coaching and evaluating), performance improvement initiatives, a collaborative environment, and initiating personnel actions, when necessary, in accordance with Human Resource policies and organization philosophy. The director ensures financial viability by managing both applicable revenue and expenses with attention to cost management, productivity in assigned cost centers, and tactical execution of Lean concepts. The director establishes and maintains effective working relationships with medical staff, organizational leaders, and other departments and fosters a collaborative environment with department leadership and staff in order to achieve department goals. In addition to the above, the Quality Management Director is responsible for regulatory and accreditation survey coordination throughout the organization, managing the medical staff office to coordinate credentialing and other activities for the hospital and the long term care facility, and managing the CME program for compliance with IMQ or other standards to maintain accreditation status. Acts as a liaison between the hospital and medical staff participating with medical staff and hospital leaders in planning, development, decision-making and administration of medical and professional staff activities in accordance with federal and state laws, Joint Commission requirements, medical staff bylaws and/or rules and regulations, and policies. Is authorized to request information on all performance improvement activities including those of the medical staff, allied health services and other clinical caregivers for the reporting of such information.
Responsibilities
- Carry out the strategy and vision for assigned departments including Quality Management, Medical Staff Services, and Infection Prevention.
- Manage overall operations of assigned departments including assessing, planning, implementing, and evaluating care/services.
- Ensure quality programs and patient safety while exceeding customer expectations.
- Develop and mentor a high-performing team through effective employee relations and performance improvement initiatives.
- Manage financial viability by overseeing revenue and expenses, focusing on cost management and productivity.
- Establish and maintain effective working relationships with medical staff and organizational leaders.
- Coordinate regulatory and accreditation survey processes.
- Manage the medical staff office for credentialing and other activities.
- Oversee the CME program for compliance with accreditation standards.
- Act as a liaison between the hospital and medical staff.
Requirements
- Five years of progressive quality management experience in an acute care hospital or health system.
- Thorough knowledge of patient care, healthcare systems, and regulatory body inspection.
- Demonstrated ability to facilitate change and work with organized medical staff.
- Analytical, customer service, and financial skills to measure outcomes of performance improvement processes.
Nice-to-haves
- Implementing the rapid-cycle change model of quality improvement.
- Integrating quality databases with operational IT systems.
- Utilizing statistical process control and analytical statistics to measure small area variation.
- Developing quality dashboards.
- Developing physician profiles.
- Implementing patient safety systems.
- Implementing patient satisfaction systems.
- Leading a successful TJC survey.
- Managing credentialing/privileging systems (electronic or manual).
- Coordinating CME programs for organized medical staff.
