St. Charles Health System
Overview
The Director of Quality Management provides oversight and direction to the St. Charles Health System quality and safety programs to achieve clinical quality performance improvement, mortality review and reduction, quality assessments, quality data analysis and reporting (including external quality reporting and clinical registries for benchmarking and reporting). This leader oversees regulatory compliance, accreditation status, and infection prevention. Collaborates with Risk Management & Patient Safety, and Environment of Care to improve and maintain a safe environment for patients and caregivers. This role supports clinical care and related functions to enhance safety and the patient, family, caregiver, and organizational experience. This position manages caregivers in the Quality Management Department.
Essential Functions and Duties
Partner with campus executive leadership teams and departments to ensure quality and safety programs effectively measure, assess, and continuously improve the care and safety of services provided.
Serve as a key partner for Nursing, Medical Staff, and administrative leaders to achieve System Quality KPI goals and advance clinical excellence through continuous quality improvement.
Collaborate with executive leadership to set goals and strategic direction for QM units; oversee Regulatory Affairs, Accreditation & Safety, Quality Data, Quality Improvement, and Infection Prevention. Develop, implement, and monitor the QM annual plan and budgets toward KPI goals. Assist site leadership to create annual written quality assurance improvement plans (QAPI) and monitor progress.
Promote a Culture of Excellence and a non-punitive response to reporting.
Stay up to date with state and federal statutes, regulations, and accreditation policies related to patient care; review and update policies as needed and create new policies as approved.
Proactively evaluate organizational clinical quality using internal assessments and external benchmarking; lead clinical quality data analytics and reporting and implement evidence-based strategies.
Oversee Infection Prevention and Control Plan; maintain annual risk assessment and program plan; oversee safety audits and required regulatory audits for all care levels.
Prepare quality management reports for leadership with KPIs, strategies, barriers, and present to the Medical Executive Committee, Clinical Leadership Council, and Board Safety and Quality Committee.
Advise Executive Leadership and Legal & Risk on quality management and process improvement opportunities and initiatives.
Coordinate with Legal and Compliance to liaise with external regulatory agencies for patient and physician reporting, event investigation and response (e.g., Oregon Health Authority).
Support hospital executive teams to develop, implement, and monitor programs, policies, and procedures in line with SCHS, OSHA, Joint Commission, and other standards.
Manage accreditation, regulation, and licensing activities; prepare organization for reporting, surveys, and inspections; develop assessments, audits, and action plan responses (e.g., TJC, CMS, CLIA, OAR, OSHA).
Collaborate with Business Intelligence, IT, and clinical leadership to ensure performance data is analyzed, communicated, and provided to achieve KPI goals.
Engage leadership in process and quality improvements based on best practices and standards, in partnership with Lean Improvement Office and operations.
Participate in regional and statewide quality improvement/patient safety initiatives and represent SCHS interests.
Staff and participate in Clinical Leadership Council and Safety and Quality Committee of the Board of Directors; educate and communicate with providers and caregivers about safety events and response plans.
Support professional growth and development across the QM department; hire, coach, and evaluate direct reports; ensure compliance and safety requirements are current.
Deliver high-quality customer service; maintain professionalism and confidentiality; comply with applicable laws, policies, and procedures; uphold organizational integrity and report violations as required.
Support the organization’s vision, mission, and values; champion Lean continuous improvement.
May perform additional duties of similar complexity as required.
Education Required:
Master’s degree in healthcare administration, public health administration, nursing, or other health-related field.
Licensure/Certification/Registration
Required:
Lean leader training. Valid Oregon driver’s license and ability to meet SCHS driving requirements. Ability to travel to business functions/trainings/meetings and all SCHS worksites.
Certified Professional in Healthcare Quality (CPHQ), or completed within one year of hire.
Experience Required:
Minimum of seven (7) years of quality improvement experience in a healthcare setting. Three (3) years in a management role within healthcare operations addressing regulatory, patient safety, and/or clinical risk issues. Demonstrated knowledge of governmental and other regulatory standards/guidelines related to healthcare quality improvement (examples include Joint Commission, AHRQ, CMS, IHI, NQF).
Seniorities and Employment
Seniority level:
Director
Employment type:
Full-time
Job function:
Quality Assurance
Industries:
Hospitals and Health Care
Referrals increase your chances of interviewing at St. Charles Health System. Get notified about new Director Quality Management jobs in Bend, OR.
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The Director of Quality Management provides oversight and direction to the St. Charles Health System quality and safety programs to achieve clinical quality performance improvement, mortality review and reduction, quality assessments, quality data analysis and reporting (including external quality reporting and clinical registries for benchmarking and reporting). This leader oversees regulatory compliance, accreditation status, and infection prevention. Collaborates with Risk Management & Patient Safety, and Environment of Care to improve and maintain a safe environment for patients and caregivers. This role supports clinical care and related functions to enhance safety and the patient, family, caregiver, and organizational experience. This position manages caregivers in the Quality Management Department.
Essential Functions and Duties
Partner with campus executive leadership teams and departments to ensure quality and safety programs effectively measure, assess, and continuously improve the care and safety of services provided.
Serve as a key partner for Nursing, Medical Staff, and administrative leaders to achieve System Quality KPI goals and advance clinical excellence through continuous quality improvement.
Collaborate with executive leadership to set goals and strategic direction for QM units; oversee Regulatory Affairs, Accreditation & Safety, Quality Data, Quality Improvement, and Infection Prevention. Develop, implement, and monitor the QM annual plan and budgets toward KPI goals. Assist site leadership to create annual written quality assurance improvement plans (QAPI) and monitor progress.
Promote a Culture of Excellence and a non-punitive response to reporting.
Stay up to date with state and federal statutes, regulations, and accreditation policies related to patient care; review and update policies as needed and create new policies as approved.
Proactively evaluate organizational clinical quality using internal assessments and external benchmarking; lead clinical quality data analytics and reporting and implement evidence-based strategies.
Oversee Infection Prevention and Control Plan; maintain annual risk assessment and program plan; oversee safety audits and required regulatory audits for all care levels.
Prepare quality management reports for leadership with KPIs, strategies, barriers, and present to the Medical Executive Committee, Clinical Leadership Council, and Board Safety and Quality Committee.
Advise Executive Leadership and Legal & Risk on quality management and process improvement opportunities and initiatives.
Coordinate with Legal and Compliance to liaise with external regulatory agencies for patient and physician reporting, event investigation and response (e.g., Oregon Health Authority).
Support hospital executive teams to develop, implement, and monitor programs, policies, and procedures in line with SCHS, OSHA, Joint Commission, and other standards.
Manage accreditation, regulation, and licensing activities; prepare organization for reporting, surveys, and inspections; develop assessments, audits, and action plan responses (e.g., TJC, CMS, CLIA, OAR, OSHA).
Collaborate with Business Intelligence, IT, and clinical leadership to ensure performance data is analyzed, communicated, and provided to achieve KPI goals.
Engage leadership in process and quality improvements based on best practices and standards, in partnership with Lean Improvement Office and operations.
Participate in regional and statewide quality improvement/patient safety initiatives and represent SCHS interests.
Staff and participate in Clinical Leadership Council and Safety and Quality Committee of the Board of Directors; educate and communicate with providers and caregivers about safety events and response plans.
Support professional growth and development across the QM department; hire, coach, and evaluate direct reports; ensure compliance and safety requirements are current.
Deliver high-quality customer service; maintain professionalism and confidentiality; comply with applicable laws, policies, and procedures; uphold organizational integrity and report violations as required.
Support the organization’s vision, mission, and values; champion Lean continuous improvement.
May perform additional duties of similar complexity as required.
Education Required:
Master’s degree in healthcare administration, public health administration, nursing, or other health-related field.
Licensure/Certification/Registration
Required:
Lean leader training. Valid Oregon driver’s license and ability to meet SCHS driving requirements. Ability to travel to business functions/trainings/meetings and all SCHS worksites.
Certified Professional in Healthcare Quality (CPHQ), or completed within one year of hire.
Experience Required:
Minimum of seven (7) years of quality improvement experience in a healthcare setting. Three (3) years in a management role within healthcare operations addressing regulatory, patient safety, and/or clinical risk issues. Demonstrated knowledge of governmental and other regulatory standards/guidelines related to healthcare quality improvement (examples include Joint Commission, AHRQ, CMS, IHI, NQF).
Seniorities and Employment
Seniority level:
Director
Employment type:
Full-time
Job function:
Quality Assurance
Industries:
Hospitals and Health Care
Referrals increase your chances of interviewing at St. Charles Health System. Get notified about new Director Quality Management jobs in Bend, OR.
#J-18808-Ljbffr