System Director of Quality and Performance Improvement

Overview

The System Director of Quality and Performance Improvement reports to the Vice President of Quality and

Clinical Excellence and will assist in the planning and execution of the organization's journey to high reliability

and a zero-harm culture to realize exceptional outcomes for our patients. This leader will help shape, then

execute, the quality assurance and performance improvement plan. They will support clinical departments and

hospitals across the system in evaluating outcomes to support improvements in objectives around

standardization and utilization.

She/He will perform a key leadership role in the development of an organization-wide culture of safety and

quality improvement, informing the evaluation and implementation of performance improvement (PI) models,

assessing PI education needs, linking PI activities and data with strategic goals. She/He will oversee the

database system management utilized to abstract, analyze and report national quality measure outcomes to

regulatory agencies and quality improvement benchmarking platforms.

Responsibilities

Incorporates ARH’s vision, missions and values in goals and programs within Quality and Performance

Improvement.

Interprets impact of broad scope organizational change for staff and develops change strategies for successful

implementation.

Develops and manages operational initiatives with measurable outcomes.

Formulates objectives, goals and strategies collaboratively with other stakeholders.

Prepares and delivers reports to operational leadership outlining progress toward meeting annual goals and

objectives, to include performance related to clinical activity, quality, and safety.

Manage and direct all activities within area of responsibility.

Continually assesses all services, identifies problems, utilizes data to analyze and propose innovative approaches

for solutions.

Maintain records related to operations and services that are complete, accurate, available, and in compliance

with all legal, regulatory, and policy requirements.

Engages staff and other stakeholders in continuous improvement of systems and processes; manages resources

for staff participation in improvement work activities.

Ensures effective facilitation of improvement teams and development of leadership skills to ensure overall

effectiveness of the meetings.

Organizes and prioritizes time and resources to manage efficiency.

Remains current of new trends and best practices and incorporates into Quality - Patient Safety practices and

programs.

Articulates and enforces standards for quality and performance improvement in the delivery of exceptional

patient care.

Develops and implements innovative systems and processes that improve staff and patient quality and safety.

Demonstrates achievable and measurable results and develop action plans for improvement.

Initiates, monitors and enforces regulatory requirements.

Holds self and others accountable to policy, standards and commitments and provides timely follow through on

questions and concerns.

Ensures development of Quality and Performance Improvement initiatives to improve patient satisfaction and

family centered care.

Develops and implements clinical outcome measures for quality improvement, cost and complication reduction,

and the implementation of evidence-based practice.

Incorporates the use of evidence-based practice and appreciative enquiry into program development and

improvement activities.

Actively listens to staff ideas and concerns, assesses others communication styles and adapts to them.

Effectively facilitates Quality meetings at the system, local and organizational level.

Creates bi-directional systems that effectively communicate information and data, utilizing multiple methods.

Articulates and presents data, information and ideas in a clear and concise manner.

Communicates opinions and ideas in a non-threatening and nonjudgmental manner to staff, peers and others.

Communicates with physicians, department leaders, and senior administrators to maintain coordination with

other ARH programs.

Demonstrates empathy and concern while ensuring Quality goals are met.

Manages complex interdepartmental and interdisciplinary relationships to assure collaboration and

effective/efficient operations within Quality.

Creates an environment that encourages diverse opinions, recognizes differences and incorporates into process

and services.

Identifies lack of competency in others related to performance and establishes a plan which includes goals,

interventions and measures.

Maintains membership in professional organization(s) to develop knowledge and resources through networking,

continuing education, and participation in national, regional, and/or local activities.

Leads and/or serves on a variety of appropriate internal and external committees to represent Quality and

Performance Improvement at ARH.

Serves as a representative of Quality and Performance Improvement to ARH in order to facilitate the shared

interests and relationship between all parties.

Performs other duties as assigned

Complies with all policies and standards

Qualifications

Education (experience can be substituted for education)

Bachelors Degree in Nursing, other clinical-related field, or other healthcare profession Required.

Masters Degree in Nursing, Healthcare-related profession or Business Administration Preferred

Work Experience (education Can Be Substituted For Experience)

4-6 years Minimum of five (5) or more years of relevant experience in complex healthcare setting Required

7-9 years Seven (7+) or more years of relevant experience in complex health care setting Preferred

1-3 years Two (2+) or more years of manager (or higher) level experience in complex health care setting Preferred

Knowledge, Skills And Abilities

Excellent communication and interpersonal skills that include the ability to negotiate and resolve conflicts and build teams.

Demonstrated creativity and flexibility.

Ability to operate in high-pressure situations.

Excellent organizational skills.

Advanced working knowledge of Office 365 (e.g., ability to create custom pages, excel workbooks/worksheets and develop tools

using SharePoint’s advanced capabilities, cross-utilization of Microsoft Power BI, Tableau, etc.)

Demonstrated innovative approach to problem resolution.

Ability to work collaboratively across ARH entities and disciplines. Demonstrated commitment to patient- and family centered

care.

Broad knowledge of modern health care administration practices and principles within a healthcare environment in a rural

setting.

Effective analytical ability in order to develop and analyze options, recommend solutions to and solve complex problems and

issues.

Demonstrated effective managerial and administrative leadership of clinical.

Effective organizational, planning and project management abilities.

Experience in financial and programmatic presentations.

Ability to function independently and deal with multiple, simultaneous projects.

Ability to recognize personal strengths and weaknesses and develop goals for professional growth and achievement.

Ability to demonstrate a commitment to quality and excellence.

Effective Leadership Abilities

Ability to implement change in a positive, sensitive and forward- thinking manner

Planning and problem solving

Developing goals and objectives, and establishing priorities

Inspires confidence, appropriate risk taking and achievement of high standards

Self-starter with a willingness to try new ideas

Positive, can-do attitude coupled with a sense of urgency

Good judgment and ability to act decisively at the right time

Ability to persuade others and develop consensus

Effective communication skills both in written and verbal presentation with a communication style that is open and foster trust,

credibility and understanding.

Ability to effect collaborative and promote teamwork

Ability to ensure a high level of customer satisfaction including employees, patients, visitors, referring physicians and external

stakeholders

Ability to create win/win solutions and relationships

Licenses and Certifications

Registered Nurse – Single State Or Compact Preferred

Certified Professional in Healthcare Quality

(CPHQ) or other related professional

certification, Required or plan to obtain within

one (1) year. Required

Lean Six Sigma Certification, Highly Desirable Preferred

Project Management Professional certification