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Senior Director of Quality

Company: Surgery Partners
Location: Lubbock
Posted on: June 12, 2021

Job Description:

GENERAL SUMMARY:

The Senior Director of Quality is responsible for the oversight and management of the following Departments/ Department Directors/Leaders: Medical Staff Services, Infection Prevention, Risk Management and Quality. The position requires at least 10 years' experience in related areas as well as at least 5 + years in a leadership position. CPHRM, CPHQ, CIC, or other hospital related certification strongly desired. Extensive experience with CMS Conditions of Participation-interpretation, maintaining compliance, action plans, etc. as well as knowledge of core measures, infection prevention/NHSN reporting, credentialing requirements, and risk management matters. Ability to lead with positive influence.

ESSENTIAL FUNCTIONS:

* Oversee infection prevention, quality management and risk management and medical staff services. * Ensures compliance with all applicable regulatory standards within the hospital. * Determines the quantity, qualification, and competence of department personnel. * Ensures Administrative Policies and Procedures are appropriately administered in assigned areas. * Maintains a positive work environment and promotes team efforts. * Demonstrates effective leadership skills of delegation, organization and coordination in managing multiple departments. * Direct/assist with quality management/utilization review and ensure patient quality/safety is maintained. * Oversee quality improvement and accreditation and develop the quality improvement annual plan for the hospital, which is in accordance with Federal and Texas laws, regulations and the CMS accreditation standards. * Coordinates the Quality Improvement Committee and medical staff activities. * Chairs the Departmental Quality Committee. * Provides quality data to the Executive team as requested. * Budgets for hospital quality improvement and the CMS accreditation needs. * Works with medical staff and hospital staff in the Implementation of the hospital quality and accreditation programs. * Supervises, directs and evaluates, and hires quality and departmental staff in their performance of their work. * Oversee the organization, analysis and management of all Risk Management Patient Safety activities of Lubbock Heart and Surgical Hospital, NorthStar and TPG. * Acts as a subject matter expert, resource, internal consultant, and educator for risk management issues. * Identifies strategies and solutions to enhance the healthcare operations environment and initiates techniques to reduce exposures to risks. * Provides consultation and assistance to facility leadership, staff, and physicians on day to day risk management issues and provide assistance to System Legal and Risk Management Services as needed. * Serve on appropriate clinical and non-clinical committees where risk management expertise is beneficial in a capacity of expert advisor or consultant or attend as appropriate. * Review and recommend new or amended policies and procedures including providing support for the policy and procedure committee. * Participate in and support Emergency Preparedness initiatives. * Support system Risk Management goals and objectives as well as facility-based goals which contribute to the achievement of the overall strategic objectives of the organization. * Oversee and ensure that all aspects of the credentialing, re-credentialing and privileging processes for all medical providers who provide patient care at LHSH, NorthStar and TPG are in compliance with all regulations. * Additional duties as assigned.

MINIMUM KNOWLEDGE AND SKILLS REQUIRED:

* Knowledgeable in the principles of human resources administration, quality assurance and performance improvement. * Ability to communicate effectively both verbally and in writing. * Ability to establish and maintain effective relationships within and outside the organization. * Effective public speaking skills, as well as ability to develop and conduct effective presentations. * Excellent interpersonal communication, problem solving and conflict resolution skills. * Possession of analytical decision-making skills necessary to quickly assess and resolve complex logistical, technical problems and issues. * Ability to train, motivate and supervise subordinate staff. * Ability to address and manage conflict in a direct and professional manner. * Ability to build collaborative relationships with providers. * High emotional intelligence as evidenced by ability to evaluate/perceive a situation from multiple lenses and understand various perspectives in coming to problem resolution.

MINIMUM EDUCATION AND EXPERIENCE REQUIRED:

* Master's degree preferred in Nursing or Health Care related field required from an accredited college/university. * At least 10 years' experience in related areas. * 5 + years' experience in upper level management at a comparable or larger facility.

LICENSURE AND CERTIFICATION:

* CPHRM, CPHQ, CIC or other hospital related certification strongly desired.

ENVIRONMENTAL AND PHYSICAL REQUIREMENTS:

* The employee works in a temperature controlled environment. * Must be able to read, write and speak English fluently, have cognitive skills for math. Vision for near, mid-range, far and accommodation. Hearing for low, medium, and high pitch. * Communication skills to deal well with employees, patients, families and physicians. * Job requires physical ability for standing, sitting, crouching, kneeling, frequent walking, reaching with reaching above head and below waist. * May be occasionally subject to irregular hours.

Keywords: Surgery Partners, Lubbock , Senior Director of Quality, Other , Lubbock, Texas

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