The Director of Quality leads a systemwide program to understand and improve clinical outcomes throughout Northern Arizona Healthcare (NAH). This position has oversight and responsibility for the development and implementation of a comprehensive quality strategy. Serves as a thought leader that integrates the work of Infection Prevention, Patient Safety, Accreditation, Care Coordination, Consumer Experience, Nursing, Medical Staff and other disciplines to develop and execute meaningful quality initiatives that improve health outcomes while constantly prioritizing the safety and wellbeing of front line caregivers and other NAH team-members.
The Director of Quality advances high reliability by synthesizing knowledge of the regulatory and accreditation environment, payor trends, and available internal and external data to identify opportunities, set goals and establish areas of focus for inpatient and ambulatory care settings. Directs the planning and execution of strategies and tactics necessary to achieve organizational goals and deliver high quality, cost conscious care to the communities served by the healthcare system.
This position reports to the VP of Care Transformation and works closely with the Physician Executive in Quality and Safety and other members of the quality leadership team to set strategic goals and establish the overall vision for quality and safety throughout NAH.
Quality Leadership and Integration * Establishes and oversees the development and implementation of quality improvement short and long-range goals and objectives. Collaborates with leaders and process owners to determine milestones to achievement of goals. Reviews analyses and reports of various activities to determine progress. * Develops comprehensive strategies to improve desired health outcomes, Centers for Medicare and Medicaid Services (CMS) ratings, Leapfrog letter grades, and The Joint Commission (TJC) standards of care. Strategies and associated tactics are well-thought out and generated from analysis of internal and external data, evidence-based practice and knowledge of care delivery and payment models. * Builds collaborative partnerships with executives, physicians, clinical leaders and front-line staff to increase participation and local-ownership of quality improvement activities and associated outcomes. * Formulates and institutes effective quality improvement plans, policies, procedures and programs. * Creates learning opportunities that advance systems thinking and highly-reliable, patient-centered care. |
Quality Review and Accountability * Translates data into insights using a format that allows work units, service lines, executives and the board to make informed decisions. * Designs abstraction, data collection and other review processes that support mandatory Inpatient Quality Reporting (IQR), Outpatient Quality Reporting (OQR), and Ambulatory Surgery Center (ASC) reporting requirements, TJC standards of care, and annual or long-term quality goals, plans and initiatives. Uses inter-rater reliability and other review processes to ensure data accuracy. * Utilizes information from quality review including disease specific registries and regulatory program data to support committees, serve-line specific clinical consensus groups and inform peer-protected processes such as Ongoing Professional Practice Evaluation (OPPE), Focused Professional Practice Evaluation (FPPE), and Mortality and Morbidity (M&M) Committees. * Analyzes the appropriate utilization of healthcare services and evaluates the impact of healthcare payment models as they apply to the process of care delivery. |
Performance and Process Improvement * Oversees and directs the development and implementation of systemwide quality improvement policies, procedures and programs in conjunction with related goals and objectives. This position effectively utilizes process improvement tools to create integrated, and standardized activities that maximize health outcomes, reduce waste and ensure compliance with federal and state regulations, as well as established organizational policies and procedures. * Collaborates with executives, physicians, clinical leaders and front-line staff to identify improvement opportunities utilizing qualitative techniques, knowledge of health care operations, and systems thinking. Obtains and uses evidence-based practice and benchmark data whenever possible. * Serves as a subject matter expert in performance and process improvement, project management and change management techniques. Creates a program to build competency in these techniques for those involved in quality improvement programs and projects. * Promotes the use of standardized methods and tools including the Institute for Healthcare Improvement (IHI) model for improvement and the NAH’s DMAIC framework for process improvement. * Leads a team of quality professionals that facilitate improvement activities focused on health outcomes, avoiding harms such as health-care acquired infections and compliance with regulatory and accreditation standards. |
Health Data Analytics * Leverages the organization’s analytic environment to guide data-driven decision making and inform quality goals, plans and initiatives. * Provides on-going assessment of leading and lagging indicators for metrics that provide insight into the quality of care, health outcomes, and safety culture. * Ensures acquisition and integration of data from internal and external benchmarking sources. * Guides the use of qualitative and quantitative analysis methods including statistical analysis to generate insights for administrative and clinical decision making. * Utilizes appropriate data visualizations to gain insights and share information with diverse audiences from executives to front-line staff. |
Patient Safety * Works to ensure full adoption of Just Culture principles throughout the organization. Integrates Just Culture into quality and safety analyses and enterprise-wide trainings. * Assesses the impact of the organization's safety culture on quality outcomes and preventable harm. Works with the Patient Safety Committee and other hospital leaders to identify and correct behaviors that impact safety culture. * Identifies and reports any safety related incident in a timely fashion through the Midas/RDE tool; attends all safety related training programs; performs work in a safe manner; monitors care environment for possible safety issues and ensures others are also performing work in a safe manner. |
Professional Engagement * Commits to updating knowledge on performance improvement, clinical performance, change management, and project facilitation expertise. Engages in independent study, internal development courses, attending educational workshops, review of professional publications, establishment of personal networks, and participation in professional organizations. * Integrates ethical standards into practice. * Acquires and applies knowledge of applicable federal, state and local laws as well as regulatory and accreditation standards. * Tracks forecasted changes to clinical performance (e.g. CMS stars and Leapfrog scoring methodology) to ensure NAH’s ongoing success. |
Compliance/Safety * Responsible for reporting any safety-related incident in a timely fashion through the Midas/RDE tool; attends all safety-related training programs; performs work in a safe manner; monitors work environment for possible safety issues and ensures others are also performing work in a safe manner. * Stays current and complies with state and federal regulations/statutes and company policies that impact the employee's area of responsibility. * If required for the position, ensures all certifications and/or licenses are up-to-date and valid prior to expiration dates. * Completes all company mandatory modules and required job-specific training in the specified time frame. |
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