Director Quality, Safety and Patient Experience

The essential duties and responsibilities are organized according to the competency model developed by the Healthcare Leadership Alliance. The Alliance was formed as a partnership between six of the major healthcare leadership professional associations including the American College of Healthcare Executives (ACHE), Healthcare Financial Management Association (HFMA), Healthcare Information Management Systems Society (HIMSS), American Organization of Nurse Executives (AONE), American College of Physician Executives (ACPE), Medical Group Management Association and American College of Medical Practice Executives (ACMPE).

• System Thinking/Change Management

oAddress ideas, beliefs or viewpoints that should be given serious considerations.

oSynthesize and integrate divergent viewpoints for the good of the organization.

oMaintain curiosity and an eagerness to explore new knowledge and ideas.

oListen intently to understand viewpoints of key stakeholders.

oProvide visionary thinking on issues that impact the organization.

oUtilize change theory for the implementation of organizational changes.

oServe as a change agent, assisting others in understanding the importance, necessity, impact and process of change.

• Relationship Management

oBuild trusting, collaborative relationships with team members, staff, peers, physicians and administration to advance the quality, safety, experience strategic priorities.

oPartner with the Chief Nurse Executive and Chief Medical Officer to lead the quality agenda.

• Influencing Behaviors

oServe as a champion for patient care, quality, safety, experience and professional practice, and be viewed as such.

oCollaborate with medical staff to implement evidence-based practice, process improvement (protocols, policies, procedures) and support health process improvement needs (clinical management committee) across the continuum.

• Personal Development

oValue and act on feedback that is provided about one’s own strengths and opportunities.

oAssess own personal professional and career goals and undertake career planning.

oSeek mentorship from respected colleagues.

oMaximize opportunities in the utilization of external resources (Advisory Board, Site Visits, Institute for Healthcare Improvement, etc.).

• Succession Planning

oServe as a professional role model and mentor to future nursing leaders and healthcare professionals.

oEstablish mechanisms that provide for early identification and mentoring of staff with leadership potential.

oDevelop a succession plan for own position.

Key Accountabilities:Leadership Functions; Be Strategic, Influences Broadly, Develops Talent

• Works collaboratively with hospital leadership, medical staff, and the integrated healthcare team align department goals and strategies with hospital, region, and system strategic goals.
• In collaboration with the leadership team, contributes to the development of the organization’s Performance Improvement Plan. Targets outcomes that are evidence-based.Ensures improvement and sustainment of processes through utilization of the most current evidence.Assures reliable and consistent outcomes.
• Assists in the development of performance indicators, methods of data collection, production of reports, and analysis of quality-related information.Oversees and directs department(s) and organizational performance based on critical factors.
• Oversees daily operations to ensure delivery of high-quality services and support and execution of tactics designed to meet strategic goals. Provides ongoing monitoring and oversight to annually assess effectiveness of department and organizational outcomes.
• Assumes leadership role in the development of process improvements that solve operational problems, drives cost-effective practices and improves quality, service, experience and productivity.
• Assumes leadership role in the development of process improvement opportunities related to changes in clinical practice and workflows in support of organizational goals.Applies innovative and creative skills to ensure the process improvement opportunities are identified and addressed.
• Coordinates activities of Quality Committees with appropriate personnel.Provides organizational leadership and a common infrastructure for reporting organizational performance and progress on improvement initiatives.
• Ensures processes in support of accurate and high performing publicly reported quality data, quality goals and applicable data registries.
• Reviews, reports and adjusts practices in order to meet necessary regulatory and legal standards.
• Oversees the events reporting process, root cause analyses, investigations, and requests from the claims team (including management of subpoenas, summons and complaints, and coordination of legal documents related to hospital liability).Participates on UPH system initiatives and programs to mitigate risks in the facility which have been identified at other hospitals, resulting in reduced costs, adverse patient outcomes and ultimately safer patient process and care.
• Provides leadership and responsibility for accreditation and regulatory survey readiness.
• Assures effective and efficient operations of clinical informatics.
• Serves as a coach and resource focused on an exceptional patient experience as a key differentiator.
• Collaborate with regional stakeholders to establish annual quality, safety and experience targets for organization and individual departments.
• Serves as an influential champion for UnityPoint Health’s Safety program, supporting a fair and just culture of safety, accountability and organizational learning.
• Provides direction, supervision and support to team members.Delegates accountability and responsibility appropriately to leadership team.
• Ensures an effective program is in place for staff assessment and development, career achievement and growth opportunities and competency validation.
• Ensures effective recruitment, selection, supervision and retention of direct reports and departments reporting to Director.

50%

Key Accountability:Drives Execution

• Identifies future skill sets needed to remain competitive.
• Measures and analyzes performance from various perspectives, i.e. customer, team member, growth and development, business and fiscal.
• Utilizes hospital database management, decision support and expert system programs to access information and analyze data from disparate sources for use in planning for patient care processes and systems.
• Supports performance improvement initiatives in patient experience and grievances data collection, data evaluation and implementation of action plans, assuring outcomes are met.
• Validates patient experience best practices to ensure that team members are meeting established goals and targets.

40%

Basic UPH Performance Criteria

• Demonstrates the UnityPoint Health Values and Standards of Behaviors, as well as adheres to policies, procedures, and safety guidelines.
• Demonstrates ability to meet business needs of department with regular, reliable attendance.
• Maintains current licenses and/or certifications required for the position.
• Practices and reflects knowledge of HIPAA, TJC, DNV, OSHA and other federal/state regulatory agencies guiding healthcare.
• Completes all annual education and competency requirements within the calendar year.

Is knowledgeable of hospital and department compliance requirements for federally funded healthcare programs (e.g. Medicare and Medicaid) regarding fraud, waste and abuse.Brings any questions or concerns regarding compliance to the immediate attention of hospital administrative staff.Takes appropriate action on concerns reported by department staff related to compliance.

10%

Minimum Requirements

Identify items that are minimally required to perform the essential functions of this position.

Preferred or Specialized

Not required to perform the essential functions of the position.

Education:

Undergraduate nursing degree and Master’s degree in nursing, health administration or MBA required.

Experience:

Progressive leadership experience with minimum of five years in an Operations leadership position.

Relevant clinical discipline and significant operational experience required.

Certification per discipline.

License(s)/Certification(s):

Current licensure in good standing to practice as a Registered Nurse in Iowa.

Valid driver’s license when driving any vehicle for work-related reasons.

Knowledge/Skills/Abilities:

Expertise in healthcare delivery systems and performance improvement.

Exceptional communication skills, written, verbal, and interpersonal, with evidence of collaborative practice.

Evidence of successful clinical and fiscal outcomes.

Evidence of successful change management.

Knowledge of current health care environment and its impact on patient care delivery and operations.

Knowledge of The Joint Commission, CMS, and state regulatory standards.

Knowledge of current trends and best practices in healthcare quality improvement, patient safety, experience, and clinical informatics.

Demonstrates a transformational leadership style that influences thinking and cultivates a positive, high performance culture for team members.The individual builds trusting, collaborative relationships with team members, peers, multiple disciplines and services, physicians and community leaders.

Other:

Use of usual and customary equipment used to perform essential functions of the position.

Must role model communication and team relationship skills.Must be able to direct and manage others.

May be requested on occasion to travel to conferences and meetings as a St. Luke’s Hospital representative.Must be able to make arrangements to attend these as required.

Able to manage and prioritize multiple projects simultaneously with demonstrated ability to complete projects successfully, on time and within budget.

Exceptional level of professionalism, discretion and the ability to work with highly sensitive and confidential projects.

Outstanding listening, interpersonal relationship building and problem solving.

Direct Report Job Titles

(This position completes their Performance Evaluation)

Indirect Report Job Titles

(Positions Managed by Direct Reports)

Program Manager, Risk Management/Patient Safety

Clinical Application Specialists

Program Manager, Infection Prevention

Patient Representative

Program Manager, Safety/Regulatory Compliance

Interpreters

Program Manager, Patient Experience

Data Analysis Specialist

Program Manager, Clinical Informatics

Greeters

Program Manager, Clinical Analytics

PI Advisors

Quality Review Nurses

Total number of direct reports:(number of staff for whom this position completes a performance evaluation)

11

Total number of indirect reports:(number of staff reporting up to this position’s direct reports)

13

Budget Control (Complete if position has budget responsibilities)

Annual Operating Budget (including payroll)

$2,000,000

Annual Revenue/Sales

Not applicable

Other Scope Measurements

Pertinent to the position, such as number of beds, number of units/departments, number of employees leading, cases per month, etc.

Item

Number

Mental/Cognitive Demands:

(List any special mental and cognitive abilities required by the position in your specific environment)

• Performs effectively under high stress of continual demands and deadlines.
• Ability to perform multiple concurrent tasks subject to frequent change.
• Ability to understand and deal effectively with problems and opportunities.
• Exercises sound judgement, seeking advice when appropriate.
• Ability to think, prepare and act objectively and analytically.
• Ability to interpret, evaluate and present data in an effective and understandable format.
• Ability to deal with people effectively and respond professionally in all situations.
• Works independently, takes initiative, and possesses good organizational abilities.
• Strong commitment to providing excellent service to internal and external customers.
• Ability to proactively create the healthcare environment of the future.