Division Administrative Director of Quality and Patient Safety
Medical City Healthcare
Medical City Healthcare is one of the region's largest, most comprehensive health care providers and includes 14 hospitals, 7 off-campus emergency rooms, more than 50 ambulatory sites, more than 7,000 active physicians and 15,000 employees in the Dallas-Fort Worth area.
Responsible for providing direction, analytical and QM/RM support for initiatives and projects at the system level including but not limited to data analysis, QM/RM facilitation/problem solving, and coordinating the implementation of process to assure regulatory compliance.
Provide assistance to the hospital QM and RM departments and senior management (facility and division) in a professional and timely fashion.
Direct QM/RM activities of NTXD market and division teams as needed.
Aware of and participate in the Corporate Ethics and Compliance Program.
Assist division facilities in improving QM/RM processes by providing consultative services that assure a proactive versus reactive approach.
Develop, identify, and analyze data and information for division-wide QM/RM initiatives. Assist customers in appropriate utilization of data from process improvement initiatives.
Direct and lead activities of the Quality Committee of the Board in collaboration with chairperson and VP of Quality and Patient Safety.
Assist facilities in TJC survey preparation including assisting with implementation of recommendations from corporate QRS findings.
Direct the resolution of TJC or other regulatory issues that have system wide impact as directed by supervisor.
Support the activities of key market and division improvement/strategic teams including but not limited to Safety Officers, Division Perinatal Committee, Division Infection Control, Division Pharmacy, Division Emergency Preparedness and Specialty ADHOC Committees.
Provide and coordinate quality improvement and regulatory related education for hospital and medical staff as deemed necessary by senior management.
Coordinate Premium Credit program for the division.
Orient new QM/RM directors to market and division processes.
Represent the division at corporate meetings upon request of supervisor.
KNOWLEDGE, SKILLS & ABILITIES:
Knowledge of regulatory compliance issues required, including State Health Department, CMS Conditions of Participation, QM and peer review statutes, TJC, OSHA NQF.
Knowledge of statistical process control preferred.
Team leadership and group facilitation in a healthcare setting.
Ability to apply broad knowledge and seasoned experience when addressing complex issues.
Ability to understand the meaning and implications of key financial indicators, using financial analysis to create and evaluate strategic options and opportunities.
Establish strategic direction through securing information and identifying key issues and relationships relevant to achieving a long-range goal or vision, establish and commit to a course of action to accomplish a long-range goal or vision after developing alternative courses of action based on logical assumptions and factual information and taking consideration resources, constraints, and organizational values.
Promote ideas and proposals persuasively; shape stakeholder opinions; project a positive image; work through conflicts; negotiate solutions.
Deliver clear, convincing, and well-organized presentations; project credibility and poise even in highly visible, adversarial situations.
Understand the role and interrelationship of each organizational function; have experience and skill in managing across functional and organizational lines.
Proficient in Microsoft Office applications, Internet searches, and relevant data bases.
Ability to work independently and under pressure to follow through on issues.
Ability to communicate clearly and concisely, both verbally and in writing.
Ability to establish and maintain long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations.
Ability to work effectively with other employees and external parties.
Bachelor's degree in healthcare related field or comparable experience required. Master's degree in healthcare or related field preferred.
4-5 years experience in acute hospital QM/RM at a director level.
1-2 years experience with quality improvement as a team leader and/or facilitator.
QM/RM techniques, team leadership, group facilitation and statistical/data analysis required.
Experience with The Joint Commission (TJC), other regulatory standards, and other organization-wide survey preparation.
3-4 years experience with data analysis in a healthcare setting. Teaching experience in QM/RM preferred. Supervisory/management experience preferred.