Location: Poughkeepsie,NY, USA
* Competitive Sign On Bonus*
Nuvance Health has a network of convenient hospital and outpatient locations - Danbury Hospital, New Milford Hospital, Norwalk Hospital and Sharon Hospital in Connecticut, and Northern Dutchess Hospital, Putnam Hospital Center, and Vassar Brothers Medical Center in New York - plus multiple primary and specialty care physician practices locations, including The Heart Center, a leading provider of cardiology care, and two urgent care offices. Non-acute care is offered through various affiliates, including the Thompson House for rehabilitation and skilled nursing services, and the Home Care organizations.
Title: Director of Quality
Reports To: AVP Nuvance Health Quality
Department: Quality
FLSA Status: Exempt
Purpose: The Director of Quality serves as a highly visible and engaged champion for quality, safety, and performance improvement across the organization. In this key leadership role, the Director will oversee and manage the hospital-wide quality assurance and performance improvement program, working closely with staff, leaders, and the medical staff to ensure the delivery of safe, timely, effective, efficient, equitable, and patient-centered care to all patients.
Under direction from the AVP of Nuvance Health Quality & the Chief Quality Officer, the Director helps lead the organization to achieve outstanding performance on nationally recognized metrics of patient care quality and clinical outcomes. The Director is a key contributor in helping to create a Just Culture within the organization and putting in place the elements needed to be a high-reliability organization.
She/he leads the work necessary to ensure the organization meets all Joint Commission and CMS/NY State Department of Health quality regulatory requirements and serves as the point person to manage external surveys and reviews. The Director ensures that adverse events & occurrences are reviewed and responded to in a timely manner, facilitates root cause analyses, and the development & monitoring of corrective actions to ensure improvement.
Essential Responsibilities:
1. In collaboration with hospital and corporate leadership, helps develop and implement the annual Quality and Safety Plan which establishes specific goals, targets, and actions needed to improve patient care and clinical outcomes.
2. Manage the hospital-wide Quality and Performance Improvement program in order to assess the quality performance of all key departments and service lines, identify improvement opportunities, develop work plans and engage teams necessary to improve processes, and provide follow-up & monitoring to evaluate progress and ensure process changes are hardwired.
3. Collaborate with staff, medical staff, and hospital leaders to ensure meaningful and actionable quality data, reports, and dashboards are in place and being used on a consistent basis to allow the organization to understand its current state of quality performance and where focused improvement efforts may be needed.
4. Co-chair the hospital's Quality & Performance Improvement Committee (QPIC). Set agendas and preps materials and presenters as needed to effectively report on the quality metrics and results. Reports on hospital quality dashboards, serious safety events, regulatory survey results, quality improvement projects, and other topics of importance based on the QPIC annual calendar.
5. Effectively lead, coach, mentor, and develop a high-performing Quality team by creating a positive workplace that inspires and motivates, provides adequate reward and recognition of efforts, behaviors, and results, and leads to high levels of employee engagement.
6. Coordinate the hospital's physician peer review processes including preparing cases for review, ensuring a consistent and thorough review of cases by the divisions and departments of the medical staff, documenting of peer review results and findings, developing improvement plans when needed, and monitoring for the success of actions taken to improve physician performance.
7. Provide leadership and support for a wide variety of improvement projects across the organization including but not limited to patient falls, readmissions, sepsis, hospital-acquired conditions & patient safety indicators, mortalities, infections, Emergency Dept throughput, patient experience, and more.
8. Serve as a visible role model and champion for quality improvement for all others to emulate. Helps coach, mentor, and guide others in the use & science of quality improvement tools, methods, and data to increase understanding and use so that quality and safety can be improved across the organization in a consistent and effective way.
9. Identify & implement actions, monitoring, and lead teams necessary to achieve and sustain continual regulatory compliance and survey readiness for external agencies such as The Joint Commission, the NY State Department of Health, the Centers for Medicare & Medicaid Services, among others. Chair the organization's Regulatory Readiness committee.
10. Oversee the organization's incident reporting process. Ensure timely review & response to reports, provide follow-up & problem-solving as needed, working collaboratively with Risk Management & Patient Safety and other department leaders and medical staff.
11. Facilitate root cause analyses (RCA's) and develop corrective action plans (CAPs) to improve safety and prevent reoccurrence. Monitor action plans to ensure improvements are hardwired.
12. Collaborates with Risk Management and Patient Safety to ensure effective ongoing risk reduction and patient safety improvements while working to create a Just Culture within the organization.
13. Comply with all organizational policies and ensure compliance with applicable laws and regulations.
14. Maintain contemporary professional knowledge and education.
15. Demonstrates regular, reliable, and predictable attendance.
16. Performs other duties as required including serving as the Administrator-on-Call on a scheduled basis.
Leadership Skill Requirements:
* Action and Results-Oriented: Ability to establish key goals, drive and track results among multiple decision-makers and stakeholders and meet deadlines in a fast-moving environment.
* Political Savvy and Diplomacy:
* Ability to maneuver through complex, politically-charged situations and understand the dynamics and culture of the organization.
* Ability to anticipate problems and negotiate solutions with peers and senior leadership and other key stakeholders.
Ability to Build Relationships Through Integrity and Trust:
* ability to quickly gain the trust and respect of others, drive collaboration, build a teamwork environment, search for the win/win scenarios.
* Influencing Skills: Ability to lead an organization using influence, rather than possessing the direct authority of others, being sensitive, yet direct in both verbal and written communications.
* Managing Complexity: Ability to lead and drive results in a complex organization, achieving alignment between often conflicting priorities, initiatives, and people.
Functional/Technical Skills Requirements:
* Analytics and Strategy: Expertise in developing and executing data-driven approaches to enhancing business decision-making and improving operational performance (preferably in healthcare). Advanced knowledge of business intelligence best practices, familiarity with fact-based management tools and techniques to drive strategies, and continuous improvement culture.
* Communications: Excellent written and verbal communications skills.Ability to take abstract, complex, and/or technical information and break it down for a variety of audiences in a way that is meaningful for them.
a.Ability to use good judgment in stressful situations. b.Consistently demonstrates team skills and a sense of humor. c.Handles face-to-face communication with patients, families, employees, and physicians with sensitivity and empathy.
* Functional Oversight: Issue identification, gap analysis, ability to prioritize business needs, and execute solutions.
* Financial Management: Ability to understand financial reports, develop basic financial models, and identify trends, variances, and opportunities.
Education and Experience Requirements:
* Bachelor's Degree in Nursing or a related clinical field required; Master's Degree preferred.
* Five (5)+ years of Quality Leadership experience in an acute healthcare setting is required.
Minimum Knowledge, Skills, and Abilities Requirements:
* Experienced in the IHI Model for Improvement, Lean-Six Sigma, or other process improvement methods.
* Strong organization, problem-solving, and time management skills.
* Contemporary knowledge of quality processes, performance improvement, and patient safety in healthcare.
* Understands the relationship between reimbursement and performance, and the public reporting of clinical performance data.
* Exceptional level of professionalism, discretion, and the ability to work on highly sensitive and confidential projects.
* Outstanding negotiation, written and verbal communication skills
* Outstanding listening, interpersonal relationship-building, and problem-solving skills
* Able to prioritize and manage multiple projects simultaneously with demonstrated ability to complete projects successfully on time and within budget.
* Excellent leadership attributes include a positive, can-do attitude and the ability to lead, coach, mentor, and create a high-performing Quality team.
License, Registration, or Certification Requirements:
* Current NYS license as a Registered Nurse preferred.
* Certified Professional in Healthcare Quality (CPHQ) preferred.
Environmental Factors:
* Factors affecting environmental conditions may vary depending on the assigned work area and tasks. Potential environmental exposures include, but are not limited to:
* Chemicals/Commercial Products
* Experiencing challenging conditions where a professional attitude will be required
* Fumes or Airborne Particles
* Interacting with a diverse population
* Noise Level - Varies from Quiet to Very Loud
* Repetitive Motion
* Risk of Electrical Shock
Location: Vassar Brothers Medical Center
Work Type: Full-Time
Standard Hours: 40.00
FTE: 1.000000
Work Schedule: Day 8
Work Shift: 8am-5pm
Org Unit: 1099
Department: Quality Improvement
Exempt: Yes
Grade: L3
EOE, including disability/vets.
We will endeavor to make a reasonable accommodation to the known physical or mental limitations of a qualified applicant with a disability unless the accommodation would impose an undue hardship on the operation of our business. If you believe you require such assistance to complete this form or to participate in an interview, please contact Human Resources at 203-###-#### (for reasonable accommodation requests only). Please provide all information requested to assure that you are considered for current or future opportunities.
Salary Range: 57.22-106.26