Director, Quality/Performance Improvement

Kingston, New York, JOB SUMMARY Working directly under the VP, Quality Management, provides oversight to designing and administering a comprehensive hospital wide Quality Assurance/Performance Improvement with focus on the Patient Experience that meets organization strategic objectives and improves patient outcomes and quality of care. RESPONSIBILITIES Responsible for directing QA/QI Management activities by identifying areas of potential for improvement in quality, safety or other identified risks in accordance with the department and hospital mission. Directs the collection, measurement and presentation of data required for monitoring performance improvement and quality initiatives regarding patient satisfaction and experience. Oversees and designs quality dashboards as appropriate Provides leadership to the Medical Staff in identification of quality and performance improvement opportunities based on department peer review activity and organization-wide quality initiatives data. Communicates and acts as a liaison with outside agencies such as CMS, IPRO, National Research Corporation or other appropriate agency as to ensure compliance with external reporting requirements and improvement initiatives. Works closely with Vice President Quality Mgt. and all departments by serving as a resource, facilitator and consultant for hospital wide quality improvement activities including QI Teams, RCAs and other organization projects. Provides leadership to departments and teams in quality improvement activities with the integration of continuous improvement methodologies such as PDSA, Rapid Response processes, Lean Thinking, ISO9001 and performance improvement tools. Responsible for contributing to the “Quality” section on the hospital intranet site to provide staff updates on organization quality and patient safety initiatives, the Patient Experience activity. Responsible for the review, revisions and leadership of the Hospital Wide Quality Management program so as to include all performance activities and patient experience initiatives. Participates and provides expertise and support to multiple committees and programs within and external to the organization for broadening the opportunities of PI activities as driven by goals for quality, safety and customer relation QUALIFICATIONS/REQUIREMENTS EXPERIENCE 5 years experience in health care environment--preferable in acute care. At least three years in quality and/or risk management and quality improvement activities is preferred. Current experience in assessment and analysis skills. EDUCATION Registered Nurse with BSN and MSN or other healthcare degree equivalent -- desirable. LICENSES/CERTIFICATIONS Advanced computer and analytical skills. Current knowledge of NYS Health Code, DNV Standards, and CMS Quality Initiatives. Continuing education in quality improvement and management of risks. Excellent oral and written communication, interpersonal and presentation skills required. Current NYS RN Licensure. OTHER None specified SPECIAL REQUIREMENTS N/A PHYSICAL REQUIREMENTS PHYSICAL ACTIVITY ? Physical ability to investigate any area of the hospital and off site facilities. Close eye work with use of computer. OTHER PHYSICAL REQUIREMENTS ? Generally none, but may be exposed to hazard during an emergency ? ? Ability to use computer keyboard. Skill in writing reports