Job Summary:

Under general supervision, this position is responsible for Westchester Medical Center's Quality Management Program and the development and analysis of the plans and programs to support continuous quality improvement. This individual is responsible for defining project scope, developing protocols and instruments, collecting and reporting data, determining necessary process changes, guiding teams and departments to implement changes, and monitoring and documenting outcomes to ensure that quality programs meet or exceed guidelines or requirements, including value based purchasing performance and other pay for performance programs. The Senior Director of Quality & Safety participates in ensuring that the organization is well prepared

for all regulatory and accreditation surveys and meets all regulatory agency reporting requirements, and works closely with the Vice President, Quality & Safety to choose quality metrics for and ensure compliance with meaningful use requirements. This is a senior level position with responsibility for an organization-wide program to promote the delivery of high quality and fiscally responsible health care. Responsibilities include directing and supervising the integration and coordination of all components to facilitate the efficient delivery of value added care and services. Supervision is exercised over a large number of professional and support staff. Does related work as required.

Responsibilities:

In conjunction with the other department directors, directs the day to day operations of the Quality and Safety Management Department;

In conjunction with the other department directors, directs, develops, evaluates and continuously improvesthe hospital-wide performance improvement program to ensure program effectiveness through data analysis and education of employees;

Ensures efficiency, effectiveness and accuracy of data collection, analysis and reporting to drive performance improvement processes, and presents data in easy to understand dashboards that clearly display trends so as to assist department and leadership decision making;

Identifies and coordinates performance improvement activities across all departments and service lines of the organization and coaches department heads in metric choice and development, including dashboard development for ease of tracking performance and outcomes;

Participates in the development of an annual performance improvement plan for the organization in accordance with regulatory agency requirements and the organization's strategic plan;

Participates as a key member in the development of strategies to ensure meaningful use quality metrics are built into the employee health record and that data collection is pristine and reported as required;

Instrumental in ensuring that employee health record development includes required elements to meet regulatory data collection;

Coordinates the development of multidisciplinary performance improvement teams charged with developing strategies with improving quality measures outlined in commercial pay for performance contracts, and serves as facilitator for these groups to ensure successful outcomes;

Supervises and coordinates activities for external database participation and reviews contractual and reporting activities for these databases;

Assesses the Medical Center's compliance with accreditation standards and continued survey readiness, and participates with the Vice President of Quality and other directors in Quality to coach hospital leadership in survey preparation;

Oversees the medical staff and allied health care professional peer review process, including OPPE and FPPE, as well as the tracking and trending of focused issues;

Develops and implements policies and procedures for assigned areas of the Quality and Safety Department;

Develops, implements and evaluates specified components of the Quality and Safety Department to ensure efficient utilization of resources;

Works with departmental directors in the reporting and screening of incidents and occurrences to determine the next appropriate level of reporting, follow up, documentation, course of action and tracking and trending;

Works in collaboration with subject matter experts and conducts root cause analysis, including formulating questions related to events;

Works with risk management and patient relations through case referral and collaborative case analysis;

Prepares department's operating and capital budget in conjunction with the Vice President and assists with monitoring department's budgets and expense;

Oversees the management of the human resources functions for department staff and ensures appropriate levels of staff recruitment, performance, training and education, competency and professional development;

Collaborates with information systems staff to maintain current systems and plans for existing system upgrades to enhance productivity and efficiency of the operating system;

Promotes and provides quality customer service and proactively identifies and resolves customer issues that relate to quality and performance improvement activities;

Ensures all protocols, policies and procedures are in compliance with the Medical Center's policies and procedures, collective bargaining agreements, CMS and all other applicable accrediting organizations and regulatory bodies;

Qualifications/Requirements:

Experience:

Eight years of administrative or managerial experience, including five years in a hospital or health care agency responsible for quality assurance, discharge planning or clinical case management, three years of which must have been in an acute care setting.

Education:

A Bachelor's degree* in health, hospital or business administration or nursing

Substitutions: Satisfactory completion of 30 credits* toward a Master's degree may be substituted on ayear for year basis for up to two years of the above stated experience, exclusive of the specialized experience.

*Special Note: Education beyond the secondary level must be from an institution recognized or accredited by the Board of Regents of the New York State Education Department as a post-secondary, degree-granting institution.

Licenses / Certifications:

NYS Registered Nurse Preferred, CPHQ preferred