Director Quality & Outcomes

FLSA STATUS

Exempt

QUALIFICATIONS

EDUCATION

Master’s or higher degree in a related field Bachelor’s or master’s degree in nursing strongly preferred

EXPERIENCE

Five years of management experience in a healthcare environment; for interns, three years management experience in healthcare with HM performance that demonstrates leadership responsibility Two years of experience in hospital Quality/Performance Improvement with demonstrated experience in understanding and executing performance improvement concepts and activities and regulatory surveys preparation

LICENSES AND CERTIFICATIONS

Required Nationally recognized certification in quality, patient safety, regulatory, risk, or related area Preferred RN - Registered Nurse - Texas State Licensure Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency)

SKILLS AND ABILITIES

Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills, competency assessments, and performance evaluations Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially about activities impacting patient or employee safety or security Ability to use appropriate interpersonal styles and techniques to gain acceptance of ideas or plans; modifying one’s own behavior to accommodate tasks, situations and individuals involved Demonstrates the ability to interact with others in a way that gives them confidence in one’s intentions and those of the organization Demonstrates leadership qualities and critical thinking through self‑direction initiative and effective interpersonal skills and oral/written communication skills Ability to identify and understand issues, problems and opportunities, comparing data from different sources to draw conclusions; using effective approaches for choosing a course of action or developing appropriate solutions; taking action that is consistent with available facts, constraints and probable consequences Extensive knowledge of regulatory and accreditation agency requirements that impact department; stays abreast of industry changes Demonstrates highly effective communication skills—strong written communications and platform presentation abilities Ability to work effectively in a fast‑paced environment Demonstrates flexibility and adaptability in the workplace Capable of leading teams/facilitating groups, building consensus and garnering highest confidence in professionalism and work product by senior leadership Ability to work under pressure and balance many competing priorities; highly responsive and solution/action oriented Proficiency in spreadsheet, word processing, and presentation software Maintains a positive and supportive attitude and demeanor Professional handling of exposure to confidential/sensitive information Advanced knowledge of the performance improvement philosophy, methodology, tools and techniques Ability to manage and manipulate large scale longitudinal data sets covering multiple populations Skill in use of clinical and operational outcomes and comparative performance benchmark databases

ESSENTIAL FUNCTIONS

PEOPLE ESSENTIAL FUNCTIONS

Directs, develops and implements strategic and operational/high‑level projects and processes either through independent/highly autonomous work or through the facilitation of work teams to enable the effective and efficient completion of objectives. Oversees management of and ensures development for staff to meet overall objectives in terms of quality, service and cost‑effectiveness. Provides timely guidance and feedback to help others strengthen specific knowledge/skill areas needed to accomplish a task or solve a problem. Directs management responsibilities of selection, scheduling, supervision, retention, and evaluation of employees. Meets or exceeds threshold goal for department turnover and/or system metrics on employee engagement indicators. Provides leadership and communication to maintain a competent and engaged employee group by conducting regular department meetings to review policies and procedures and operational matters, rounding on all employees, completing performance appraisals, conducting new hire feedback sessions, coaching/corrective counseling, and providing recognition/commendations to achieve desired outcomes. Identifies opportunities and takes action to build strategic relationships between one’s area and other areas, teams, departments, and units to achieve business goals. Drives the promotion of teamwork within and between departments; participates and/or leads and facilitates department process improvements as needed. Communicates effectively with all levels of staff, physicians, and external groups including regulators, payors, and accrediting bodies.

SERVICE ESSENTIAL FUNCTIONS

Oversees department operations, designated projects, schedules and activities as needed to ensure that goals or objectives are accomplished within the prescribed time frame. Sets priorities and functional standards, giving direction to staff as necessary to ensure the best possible delivery of service and high customer/patient satisfaction. Drives department service standards and activities to impact department and/or system score for patient/customer‑based satisfaction, through role modeling and fostering accountability. Serves and actively participates on various entity committees as a voice for the department. Leads entity‑wide effort to educate organization regarding performance improvement philosophy, methodology, tools, techniques and emerging trends. Provides organizational leadership in clinical process improvement. Supports departmental quality resources as entity expert and partner along with supporting system‑wide strategic plan. Facilitates summary reports of key performance improvement/patient safety activities, actions, outcomes and trends for appropriate committees. Collaborates with senior management to develop and analyze meaningful outcomes reporting to improve and innovate care delivery. Utilizes benchmarking data and best practices to partner in the delivery of high‑quality and cost‑effective patient care which is in concert with the philosophy of the organization.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

Ensures a safe and effective working environment; monitors and/or revises the department safety plan and/or any specific accreditation/regulatory required safety guidelines. Responsible for staff maintenance of credentials and competencies, per accrediting/licensing agency and/or department guidelines as applicable. Employs a proactive approach in the optimization of safe outcomes and information systems by monitoring and improving the department workflow and enhancing operations, using peer‑to‑peer accountability and identifying solutions via collaboration. Implements process improvements utilizing tools such as lean principles. Role models situational awareness, using teachable moments to improve safety. Responsible for employee compliance to policies and procedures and performs associated actions upon non‑compliance (i.e., licensure/certification compliance, focal point review requirements, disaster plan, in‑services, influenza immunization, wage and hour, standard hours, timely termination submission, timely timecard approval, etc.). Develops and continuously oversees the entity‑wide performance improvement/patient safety program to optimize program effectiveness, goal achievements, contemporary state‑of‑the‑art practices, and regulatory compliance. Oversees leadership of RCA, FMEA, and other complex problem‑solving groups and with monitoring the follow‑up and action plans.

FINANCE ESSENTIAL FUNCTIONS

Develops and manages department operational and capital budgets, approvals, and ongoing maintenance of the department(s), ensuring operation in a cost‑effective manner. Proactively identifies and plans for capital needs related to current equipment and future department projects. Ensures staffing plans and schedules meet department needs that reflect understanding of the importance of cost‑effectiveness. Creates department strategies to achieve financial target and staffing needs, through optimizing productivity, supply/resource efficiency, minimizing incidental overtime and overtime percentage, and other areas according to department specifications. Collaborates with stakeholders on performance improvement activities that effectively reduce exposure to pay‑for‑performance penalties.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

Identifies and implements innovative solutions for practice or workflow changes to improve department, entity or system operations by leading unit projects and/or other department/system‑directed activities. Proactively leads task forces and committees. May represent HM at assigned community or professional organization meetings. Drives change initiatives, maintaining effectiveness when experiencing major changes in work responsibilities or environment; adjusts effectively to work within new work structures, processes, requirements or cultures. Partners effectively with stakeholders as appropriate. Ensures own career discussions occur with appropriate management. Completes and updates My Development plan on an ongoing basis. Conducts conversations with staff on their development.

SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE

Uniform: No Scrubs: No Business professional: Yes Other (department approved): No

ON‑CALL*

*Note that employees may be required to be on‑call during emergencies (ie. Disaster, Severe Weather Events, etc) regardless of selection below. On Call* Yes

TRAVEL**

**Travel specifications may vary by department** May require travel within the Houston Metropolitan area Yes May require travel outside Houston Metropolitan area Yes #J-18808-Ljbffr Houston Methodist