Director Quality Management III - Quality Management

Summary:

In a High-Reliability Organization, the Director Quality is responsible for the overall operations of the quality management program throughout the hospitals. The quality management program consists of quality, risk management, infection prevention, and safety. Acts as a resource to members of the management team in reference to guidelines for quality and safe patient care. Identify and report patient safety risk trends. Collaborates with key stakeholders to analyze patient safety risks and events. Implements action plans to mitigate safety risks. Utilizes and integrates data from internal and external sources to drive performance improvement using validated change management tools. Collaborates with leadership and clinicians to improve patient care quality and safety using trended data and action plans. Operationalizes processes to support standards compliance for regulatory bodies. Facilitates and guides the organization through continuous survey readiness activities and drives action plans to meet compliance. Ensures that the facilities’ policies and practices, as related to patient care, are within best practice guidelines and standards, as designated by all State and Federal agencies as well as certifying agencies.

The Director Quality Management III is responsible for the overall operations of quality management programs throughout Type C (Tertiary Care defined as a level above Secondary health care that includes highly specialized medical care that involves advanced and complex diagnostics, procedures, and treatments performed by medical specialists in state-of-the-art facilities) hospital facilities.

CHRISTUS Spohn Hospital Corpus Christi-Shoreline overlooking Corpus Christi Bay is the largest and foremost acute care medical facility in the region, with a full range of diagnostic and surgical specialty services in cardiac, cancer and stroke care. It is the leading emergency facility in the area and the only Level II Trauma Center in the Coastal Bend, staffed with physicians and nurses specially trained in emergency services.

• The Pavilion and the Critical Care Center house a state-of-the-art Emergency Department, ICU, Cardiac Cath Lab and surgical suites.
• A teaching facility, in affiliation with the Texas A&M University System Health Science Center College of Medicine
• Accredited Chest Pain Center
• Accredited Joint Commission Stroke Team

The Shoreline campus is a premiere facility housing many of the region’s most vital and renowned programs such as a Primary Stroke Center, nationally accredited Cancer Center and a nationally recognized Chest Pain Center. The Pavilion at CHRISTUS Spohn Hospital Corpus Christi-Shoreline houses the CHRISTUS Spohn Heart Network, which was recently recognized as one of the top 100 cardiovascular hospitals in the United States. The Heart Institute offers the most advanced diagnostic, surgical and rehabilitative cardiac services in one convenient location.

Responsibilities:

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Communicate effectively to different audiences.
• Proficient in computer skills using EXCEL, PowerPoint, MS Office, and Flowchart tools.
• Knowledgeable on High-Reliability Principles and PDSA methodology.
• Knowledgeable on payment models for quality metric performance.

Source: NAHQ Workforce Accelerator Competency Framework 2022: Eight Domains

• Quality Leadership and Integration-Advance the organization's commitment to health care quality through collaboration, learning opportunities and communication. Lead the integration of quality into the fabric of the organization through a coordinated infrastructure to achieve organizational objectives. Domain Level: Advanced.
• Performance and Process Improvement-Use performance and process improvement (PPI), project management and change management methods to support operational and clinical quality initiatives, improved performance and achieve organizational goals. Domain Level: Advanced.
• Population Health and Care Transitions-Evaluates and improve health care processes and care transitions to advance the efficient, effective, and safe care of defined populations. Domain Level: Proficient
• Health Data and Analytics- Leverage the organizations analytic environment to help guide data-driven decision-making and inform quality improvement initiatives. Domain Level: Advanced
• Regulatory and Accreditation-Direct organization wide processes for evaluating, monitoring, and improving compliance with internal and external requirements. Lead the organization's processes to prepare for, participate in, and follow up on regulatory, accreditation, and certification surveys and activities. Domain Level: Advanced
• Patients Safety-Cultivate a safe healthcare environment by promoting safe practices, nurturing a just culture, and improving processes that detect, mitigate, or prevent harm. Domain Level: Advanced
• Quality Review and Accountability-Direct activities that support compliance with organization-wide voluntary, mandatory, and contractual requirements for data acquisition, analysis, reporting, and improvement. Domain Level: Advanced
• Professional Engagement-Engage in the healthcare quality profession with a commitment to practicing ethically, enhancing one's competence, and advancing the field. Domain Level: Proficient

Requirements:

C. Licenses, Registrations, or Certifications

• CPHQ (Certified Professional in Healthcare Quality) required or within 1 year of hire.

Work Schedule:

Varies

Work Type:

Full Time

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