In collaboration with other clinical leaders in the Regional Group, is responsible for ensuring that patient care is delivered within the framework of evidence-based practice throughout the health system continuum and for understanding existing and emerging requirements in healthcare quality, safety, service/experience, and operational improvements.
Responsible for researching and recommending the annual quality management objectives. Facilitates medical staff and other committee meetings that are conducting quality and peer review activities. Directs the daily activities of the Quality Management Department and its staff responsible for the region. The Quality Management Department consists of quality, infection prevention, regulatory, risk management, and patient safety. Designs the measurement techniques, audits, and data reports that evaluate the attainment of the quality objectives of the hospital, region, and system. Educates the hospital and medical staff on matters related to quality. The Regional Director of Quality Management oversees and coordinates the process of regulatory accreditation including preparing and monitoring the hospital staff for a constant state of readiness, compliance with standards, and promoting a culture of safety. In collaboration with CHRISTUS Health & CHRISTUS Hospital Senior leaders, facility leaders, physicians, and the Board of Directors, he/she collaborates with other leaders to develop the strategic direction for the overall delivery of high-quality patient care across the continuum of health care service specifically related to improving organizational performance. This position is responsible for the design, implementation, tracking, and reporting of clinical quality of care and patient safety efforts in alignment with the corporate strategies for performance improvement.
Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
Regional leaders are responsible for effectively collaborating with local leadership teams to meet accountability measures including, but not limited to, labor productivity standards, quality metrics, associate engagement, and retention efforts, as well as service level agreements to the consumer.
Provides expertise in quality management for inpatient and hospital outpatient department delivery settings.
Works collaboratively with the Chief Medical Officer and Chief Nursing Officer on quality management initiatives.
Provides leadership and expertise for integrating CHRISTUS multidisciplinary activities into quality management processes that include the utilization of national benchmarks, internal goals, and local targets.
Works collaboratively in a team environment to promote patient quality of care and safety.
Oversees continual compliance readiness with regional leadership in providing Joint Commission and other accrediting or licensing body reviews and education.
Provides oversight for the facilitation of the Quality Council, Infection Control Council, and the Patient Safety Council.
Provides quality management reports to the Quality Management Committee, a sub-committee of the Regional Board of Directors.
Language Ability: Excellent communication skills. Ability to write reports, business correspondence, and policy and procedure manuals. Ability to effectively present information to Associates, Executive Leadership, Committees, and the Board.
Reasoning Ability: Ability to use critical thinking.
Computer Skills: Must be proficient in the use of Microsoft Excel, Word, PowerPoint, and the Internet. Source: NAHQ Workforce Accelerator Competency Framework 2022: Eight Domains
Quality Leadership and Integration- Advance the organization's commitment to health care quality through collaboration, learning opportunities and communication. Lead the integration of quality into the fabric of the organization through a coordinated infrastructure to achieve organizational objectives. Domain Level: Advanced.
Performance and Process Improvement- Use performance and process improvement (PPI), project management and change management methods to support operational and clinical quality initiatives, improved performance and achieve organizational goals. Domain Level: Advanced.
Population Health and Care Transitions- Evaluates and improve health care processes and care transitions to advance the efficient, effective, and safe care of defined populations. Domain Level: Proficient
Health Data and Analytics- Leverage the organizations analytic environment to help guide data-driven decision-making and inform quality improvement initiatives. Domain Level: Advanced
Regulatory and Accreditation- Direct organization wide processes for evaluating, monitoring, and improving compliance with internal and external requirements. Lead the organization's processes to prepare for, participate in, and follow up on regulatory, accreditation and certification surveys and activities. Domain Level: Advanced
Patients Safety- Cultivate a safe healthcare environment by promoting safe practices, nurturing a just culture, and improving processes that detect, mitigate, or prevent harm. Domain Level: Advanced
Quality Review and Accountability- Direct activities that support compliance with organization-wide voluntary, mandatory, and contractual requirements for data acquisition, analysis, reporting, and improvement. Domain Level: Advanced
Professional Engagement- Engage in the healthcare quality profession with a commitment to practicing ethically, enhancing one's competence, and advancing the field. Domain Level: Proficient
· Bachelor's degree in Health Care Administration, Nursing, or a relevant clinical discipline with evidence of additional training in Quality required.
· Master's degree in Nursing or other healthcare related profession is strongly preferred.
· 5 years of experience in a strategic quality position in a complex healthcare environment required
C. Licenses, Registrations, or Certifications
· Current Certified Professional in Health Care Quality (CPHQ) required or actively seeking the certification within 1 year of hire date.
· Current Texas license in a relevant clinical discipline is required.
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CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.