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Director of Quality in Toledo, OH at Mercy Health

Date Posted: 5/8/2018

Job Snapshot

Job Description

Job Summary

The Quality Director Leads the quality and patient safety program for the facility and off site departments/facilities. Responsible for the day to day operations of quality and case management.Works closely with nursing, physicians, leadership, residents and outpatient settings to ensure quality outcomes for the community served. Essential Functions & Responsibilities: It is expected that all of the Principal Duties and Responsibilities identified below will be performed in a manner that reflects the values of the Catholic Healthcare Partners, which are: Excellence, Human Dignity, Justice, Compassion, Sacredness of Life and Service. • Ensures the delivery of high quality, excellent care that meets or exceeds regulatory standards and requirements and payor expectations, as well as assisting the organization and the region to successfully achieve the CHP system objectives for quality and patient safety.  • Oversees quality reviews and reporting, performance improvement, analysis of serious adverse events and infection prevention, and case management.  • Collaborates closely with and assists documentation specialists, divisional patient safety officer, risk management, nursing leadership, divisional quality leadership, and medical staff for peer review activities.  • Prepares and submits quality reports as required by external agencies and payors.  • Facilitates and supports the quality, patient safety, and performance improvement committee infrastructure.  • Provides support for organizational quality, patient safety, and performance improvement committees and projects as needed. 1. Provides oversight for the development and implementation of the organization-wide quality and performance improvement plan.  Facilitates and supports the development and maintenance of a robust quality infrastructure to meet system quality objectives and regulatory standards. 2. Collaborates and acts as a resource to the organization and medical staff in the analysis, and submission of data for evaluation to ensure compliance with regulatory agencies, CMS conditions of participation, payor requirements, and medical staff bylaws. 3. Facilitates the collection of quality indicator data to provide a basis for comparative analysis with other healthcare facilities. 4. Works collaboratively with the medical staff and organizational leadership to proactively address quality and /or utilization issues.5. Manages the integrated, organization/region wide quality review program to promote operational efficiency and effectiveness.  Provides support as needed to regional and corporate initiatives related to quality, patient safety, and survey readiness. 6. Collaborates with accreditation management staff to ensure site survey readiness and compliance with regulatory requirements and conditions of participation. 7. Serves and an internal consultant and educator for performance improvement activities and patient safety processes. 8. Collaboratively participates in the market quality and patient safety initiatives designed to improve patient outcomes and experience and eliminate harm.  Identifies areas of potential risk and participates in organization wide learning and analysis to mitigate that risk. 9. Provides oversight and management of the patient grievance process including data collection, tracking and trending of data, and report to organization quality, safety and patient experience committees.  Ensures regulatory compliance with requirements for patient communication and problem resolution. 10. Establishes site-wide practices that promote a team culture to support the Institute of Medicine's Six Aims for Healthcare Quality which include care that is safe, timely, effective, efficient, equitable, and patient centered. 11. Creates an environment promoting individual and team accountability and commitment to high-quality and safe patient care. 12. Develops annual operational and capital budgets and provides oversight for departmental operations within targets. 

Qualifications - Minimum

EDUCATION, SPECIALIZED AND/OR TECHNICAL KNOWLEDGE REQUIREMENTS: Education: Required Minimum Education: BSN Specialty/Major: RN or Allied Health LicensurePreferred Education: Quality Certification; Master Degree Experience: Minimum Years and Type of Experience: 5 years clinical experience with 3-plus years of management experience demonstrating increasing responsibility and success in clinical quality improvement. Case Management experience and/or oversight preferred. Other Knowledge, Skills and Abilities Required: Through knowledge of TJC standards, CMS conditions of participation, and other regulatory standards essential.  Other Knowledge, Skills and Abilities Preferred: Excellent communication skills and ability to interact in a positive manner with members of the medical staff, organizational leadership and frontline staff. Organizational team-building, relationship building and management skills required. Understanding and ability to perform data analysis, basic statistical skills including intermediate knowledge of Excel. Proven experience with performance improvement methodologies required. Special Knowledge: • Thorough knowledge of JCAHO Standards and standards of other regulatory agencies is essential.• Ability to communicate well and interact with key members of the Medical Staff and all levels of management.• Organizational and management skills License/Registration: Required: Current Ohio R.N. Licensure or other allied health professionalPreferred: Professional in healthcare quality   


Full-time, 40 hours per week, days

May include weekends,  evenings,  nights if needed

Equal Employment Opportunity

It is our policy to  abide by all Federal and State laws, as well as, the requirements of 41 CFR 60-1.4(a), 60-300.5(a) and 60-741.5(a), prohibiting discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibiting discrimination against all individuals based on their race, color, religion, sex, sexual orientation, gender identity, or national origin.