Director of Quality

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Is the primary leader responsible for overseeing the day-to-day activities and responsible for leadership, coordination and integration of services for WVU Medicine Hospitals. Responsible for directing the overall operation of departments and clinical areas which may include: Quality, Infection Control, Regulatory, Patient and Employee Safety, Risk Management, and/or Compliance and Privacy. Responsible for guiding changes needed to reach each departmental goals for each hospital. The Director of Quality provides overall organizational leadership for performance improvement and will develop and foster effective collaboration between all departments and other affiliated services to ensure a quality focused approach to providing services, and fulfilling our quality objectives. Functions as an effective liaison and intermediary between medical staff, nursing administration, hospital leadership, entity and hospital leadership, and all other clinical and non-clinical departments. Develops new business/operational strategies to improve overall performance. Serves as a resource to help reduce costs, enhance revenues, achieve effective utilization and quality goals and objectives, analyzes and utilizes information to develop and support management decisions. Coordinates the determination of fiscal requirements of assigned departments and reviews budgetary recommendations. Facilitates Organizational compliance with the standards of all applicable Regulating Bodies Provides leadership and direction for all improvement services that support the priorities of the organization. Fosters a culture of continuous improvement and coordinates the systematic implementation of effective practices designed to reduce error and improve patient outcome.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s degree in nursing, business administration, finance, accounting, or other related field.

EXPERIENCE:

1. Five (5) years’ experience working with hospital operations with a focus in quality improvement.

2. Three (3) years’ experience in leadership.

PREFERED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Master’s degree in business administration, finance, accounting, or other related field.

2. Current licensure or temporary licensure as a Registered Professional Nurse.

EXPERIENCE:

1. Ten (10) years’ experience working with hospital operations including at least Three (5) years’ experience in Administrative Management.

2. Experience in applying Lean Management approaches to process improvement.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Administratively responsible for direction of all aspects of Quality, Patient and Employee Safety, Infection Control, Regulatory, Policy Management, , Risk Management and/or Compliance and Privacy.Leads by influence for effective Emergency Management and Life safety to assure a Hospital environment that is consistent with the objectives of both Hospitals.  Directs quality, regulatory through hospital administration and directors.     

2. Participates in operational planning and is responsible for development of goals and objectives for areas of accountability. Influencesthe establishment of standards of nursing practice and other clinical procedures within the Hospital.

3. Directs regular review of safety and quality outcomesand performance for both Hospital's strategic plans.

4. Directs and maintains application of the continuous improvement process in management of patient care delivery to achieve high quality, cost effective services.

5. Directs the preparation, control and monitoring of budgets for assigned areas.  Assures compliance with targeted fiscal objectives; discusses budget variances and modification as necessary with executive leadership.

6. Recruits and develops staff necessary for effective leadership and management of departments to achieve hospital quality and safety goals and regulatory requirements. .  Establishes and maintains standards for employee relations, motivation and morale throughout the organization.

7. Participates with governing body, management, medical staff, and clinical leaders in the organization’s decision-making structures and processes.

8. Collaborates with department managers and administrative team in order to provide recommendations for the annual operating and capital budget.

9. Leads Risk Management administrative activities by ensuring policy renewals and reporting issues to the carrier and maintaining all related records and documents.

10. Directs the Policy Committee and Interprets Hospital policies and procedures for administrative staff; implements new or modified policies and procedures as necessary. 

11. Assures applicable accreditation, licensure and regulatory standards compliance.

12. Presents evidence-based indicators and standards to measure, assess and improve quality patient outcomes and works collaboratively with departments to approve and implement these initiatives.

13. Oversees and manages the administration, coordination, performance and monitoring of operational and business activities of the entity, working collaboratively with administration.

14. Works with leadership to identify improvement priorities and goals and partners with them to deliver improvements to clinical and operational processes.

15. Implements and manages clinical procedures and regulatory processes relating to patient flow and budgets including the regulatory affairs, professional fees, billing and insurance, the maintenance and retention of related records.

16. Develop and foster effective collaboration between clinical departments and divisions to ensure an integrated approach to quality, safety, and performance improvement towards fulfilling hospital clinical goals and objectives.  Communicate effectively to facilitate positive working relationships and achieve desired outcomes. 

17. Oversee the processes that provides relevant reports, data, and education to support quality improvement and fulfill reporting needs.  Reporting needs include national benchmark surveys, national rankings, accreditation requirements, third party payer requirements, regulatory agency requirements, peer review, ongoing professional practice evaluation, and focused professional practice evaluation.

18. Supports key committees pertaining to investigation of sentinel events, safety concerns, and identification of event trends.  Oversee the development and implementation of evidence-based medicine practice guidelines to meet quality of care, safety, and efficiency needs.

19. Ensure compliance with relevant licensing, regulatory, and accreditation requirements.  Maintain knowledge and expertise in regulatory change.

20. Assist in the development, coordination and management, with the Emergency Management Director/Manager, the Emergency Operations Plans (EOP) and associated annexes and supporting policies, ensuring that the plan meets all standards set by all applicable Regulating Bodies which include; OHFLAC, TJC, and CMS.

21. Works with the Emergency Management Director/Manager to work with the both hospital’s education staff to design, develop, coordinate and implement hospital-wide and site-specific training for the both hospital EOPs.

22. Assist and direct, with the Emergency Management Director/Manager, the execution of required hospital Emergency Preparedness.

23. Represent hospital at external meetings and venues at the local, regional and state level.

24. Develops and maintains a routine reporting process to the Board of Directors, and administration with timely and relevant information on the status of programs, and periodic risk assessments on all compliance issues.

25. Coordinates and provides assistance with WVU Medicine.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Requires full body ranges of motion, manual and finger dexterity and hand-eye coordination.

2. Requires sitting for long periods of time.

3. Exposure to all patients’ elements including communicable diseases and body fluids.

4. Requires corrective vision and hearing within normal range.

5. Requires full body ranges of motion, manual and finger dexterity and hand-eye coordination.

6. Requires sitting for long periods of time.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Exposure to toxic substances, ionizing radiation, medicinal preparations and other conditions common to a clinical environment.

SKILLS AND ABILITIES:

1. Knowledge of financial mechanisms of expense and revenue.

2. Knowledge of current theoretical approaches to the delivery of nursing care and strategies for their implementation.

3. Knowledge of current leadership, management and performance improvement concepts. 

4. Knowledge of the scope and complexity of nursing care needs of the hospital’s major patient population.

5. Ability to investigate complaints, incidents and accidents involving all patients and staff in accordance with hospital policy.

6. Requires the ability to make decisions and use good judgment.

7. Requires multi-tasking, problem solving and decision making abilities.

8. Computer literacy and word processing required for the position.

9. Excellent written and verbal communication skills.

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

WMCH Weirton Medical Center

Cost Center:

609 WMCH Risk Management

Address:

601 Colliers WayWeirtonWest Virginia

Equal Opportunity Employer

West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.