The Director of Quality and Patient Safety serves as a highly visible, energetic champion of quality and performance improvement throughout San Juan Regional Medical Center (SJRMC) and San Juan Health Partners (SJHP). This role reports to the Chief Medical Officer (CMO) and works closely with senior leadership, providers, and all staff to continuously improve patient safety, quality, quality data metrics, as well as health system operations. The Director of Quality is a key contributor in developing a comprehensive system wide program to minimize patient harm through systematic organizational improvement and implementation of systems that create a culture of safety, proactively identify harm, encourage adverse event reporting, and supports thoughtful, learning-oriented analysis of safety trends and patterns. This role also facilitates decision support for teams and individuals at all levels and in all departments. Under the direction of the CMO, this role develops, directs, and leads the Organizational Excellence (Performance Improvement), Quality Management Systems, Patient Experience, and Infection Control teams. Through leadership with an emphasis on organization systematic improvement, the Director propels data into meaningful system-wide change.

Required Behaviors:

• As you go about fulfilling this mission, your work habits and work relationships should embody SJRMC's values. These values are our culture, our identity as an organization. Sacred Trust, Personal Reverence, Thoughtful Anticipation, Team Accountability, and Creative Vitality ask more of us than merely completing some list of tasks. Our values ask for a deeper level of commitment, and what is asked of us we freely give because we believe in our mission.

Required Qualifications:

• Bachelor's degree in healthcare (or related field) or ten or more (10+) years of healthcare experience with prior experience working within a hospital setting, quality-focused organization (NQF, NCQA), a provider association or society, academia, consulting firm or combination of education and experience
• At least five (5) years' experience in progressively increasing leadership positions
• CPHQ certification or equivalent in one (1) year.
• Strong knowledge of LEAN/Six Sigma methodologies, obtaining Black belt or equivalent within three (3) years of hire
• Experience in quality data measures, databases, scorecards, analysis of data, and communication of data into meaningful information
• Experience as a quality subject matter expert within a team and across an organization

Preferred Qualifications:

• Master's degree, other certifications in healthcare quality
• Deep knowledge of Performance Improvement methodologies
• Deep knowledge of CMS Quality Measures, Scorecards, data analysis, and data roll-up methodologies
• Working knowledge of MACRA, report writing, Risk/Harm Assessment, Provider Peer Review, HIM, CDI, CM, patient safety and coding

Duties and Responsibilities:

• Use data-driven focus that sets priorities for improvements that are aligned with organizational goals and strategic plan
• Oversee Performance Improvement and LEAN/Six Sigma projects and providing guidance to the entire system
• Manage quality contracts
• Manage team effectively in a rapid-changing and ambiguous environment
• Champion for the organization's culture of safety
• Develop the Quality Plan, budget, policies, and goals
• Promote standard work, best-practice, and shared leadership in a CQI/TQM LEAN Environment
• Subject matter expert in quality and performance improvement
• Oversee accuracy and timeliness of Harm and Quality Scorecards
• Ensure that the department operates within organizational frameworks
• Clearly and concisely present information to leadership, public, and staff on all levels
• Support the MEC, Senior Leadership, and Board of Directors through accurate and consistent reporting
• Respond effectively and professionally to confidential inquiries, time sensitive requests, and high-risk topics
• Oversee all quality extractions, submissions, and reporting (i.e., core measures and scorecard) writing for quality initiatives, data roll-up, and Hospital Compare Reporting
• Lead and manage the Quality Team including education, staffing, payroll, recruitment, team cohesion, coaching, counseling, and annual reviews
• Lead and direct all aspects of the quality program including strategic planning, goal setting, program development, and team functions
• Analyze, identify, and report issues or policies that have the potential to negatively impact clinical outcomes and/or the delivery of quality care
• Collaborate with the CMO to support the organization's quality committees including Quality Council, QAPI and the Medical Staff Quality & Performance Improvement Committee
• Perform other duties as assigned
• Each employee is responsible for implementing SJRMC's Service Standards into their daily work:

Safety, Courtesy, Effectiveness, and Stewardship

Physical Demands and Environmental Work Conditions:

• Moderate noise level
• Frequent interruptions
• Prolonged sitting, standing, and/or walking
• Balance fast pace and competing priorities
• Define problems, collect data, establish facts, and draw valid conclusions
• Primarily office environment with daily inclusion in operational environments
• Interpret an extensive variety of technical documents in mathematical, narrative, or diagram form