Director, Quality

Baptist Health strives to cultivate a close-knit, positive and professional environment that encourages our employees to want to come to work every day.

When you choose Baptist, you have an opportunity to play a role in providing compassionate, quality care that makes a difference in the lives of our patients and promotes joy throughout our communities.

Job Description:

Job Summary:

The Director of Quality is responsible for planning, administrating, and monitoring of consistent readiness of all quality management, regulatory requirements, and quality improvement processes. This director will establish collaborative relationships and processes with all departments but especially Nursing, Case Management and Risk Management & Safety to ensure reliable and quality patient outcomes. Direct management of: Quality Data Management and Compliance with Public Reporting, Accreditation and Regulatory Compliance, Infection Control Program, Clinical Outcomes Program and Nursing Quality.

Key Accountabilities/Principle Duties:

The following is a summary of the major functions of this individual’s job. He or she may perform other duties, both major and minor, which are not mentioned below, and specific functions may change from time to time.

1. Fiscal Responsibility

• Develops an annual operating budget and long-term capital expenditure plan as well as monitors the expenditures on an ongoing basis compared to the operating and capital budgets.
• Manages at or below budget
• Actively seeks opportunities to reduce expenses on an ongoing basis

2. Staffing Management

• Manages staffing levels consistent with fluctuations in volume and acuity.
• Uses productivity data and clinical data to improve processes and gain efficiencies in staffing.
• Assists in the development of programs that support recruitment and retention of staff.
• Determines a sufficient number of competent and qualified staff to carry out the services of the department.

3. Education and Competency of Staff

• Effectively manages and sets performance expectations for staff
• Resolves performance issues timely and in compliance with hospital human resources policies
• Ensures proper licensure and credentials of staff on an ongoing basis
• Provides for necessary training opportunities for compliance with hospital, state and Joint Commission requirements.
• Implements programs to promote staff members’ job-related advancement and educational goals.
• Provides for orientation, education, in-service training and continuing education to all staff

4. Quality Improvement

• Develops performance improvement measures and continually assesses performance against identified measures.
• Provides direction to staff on issues that impact patient care/satisfaction/customer service
• Is proactive in identifying potential problem areas and developing corrective action plans
• Actively monitors and plans for compliance with state, federal, and Accreditation requirements
• Actively executes the Corporate Compliance Program as it relates to area of responsibility
• Measures key processes and takes appropriate action to improve and control

5. Integration of Services

• Defines the scope of services provided by the department or service area and ensures care and services are rendered according to the written goals and scope of service.
• Ensures departmental services are integrated within the hospital’s primary functions.

6. Strategic Planning

• Works with administration to proactively assess the impact of legislation and management care developments on area(s) of responsibility.
• Works closely with hospital administration, medical staff, corporate counsel, defense counsel, department directors and managers.
• Supports hospital management decisions through communication with staff and execution of directives (takes accountability as a team member)
• Positions department(s) for future revenue growth, cost reduction, and quality improvement through ongoing targeted initiatives
• Works with staff to convey a clear vision of department direction, challenges, and opportunities.
• Ensures strategic, operational, programmatic, and other plans and policies support the mission, vision and values of the organization.

Minimum Education, Training and Experience Required:

A. Registered Nurse or 3-5 years experience in health care;

B. Masters degree in nursing or Master’s in other health care related field required;

C. CPHQ and/or CPHRM preferred;

D. 3-5 years progressive leadership experience.

E. Strong knowledge of state, regulatory standards/compliance, accreditation standards, data management, and performance improvement methodologies.

If you would like to be part of a growing family focused on supporting clinical excellence, teamwork and innovation, we urge you to apply now!

Baptist Health is an Equal Employment Opportunity employer.