Systems Director Quality & Process Improvement

Bristol Hospital   •  

Bristol, CT

Industry: Healthcare


5 - 7 years

Posted 32 days ago


Job Summary:

The quality department is responsible for quality and safety performance for BHHCG and operational focus for the hospital. The department has system oversight responsibility for all required regulatory and public measures. This department provides oversight and governance for the Quality Assessment and Performance Improvement mandates for CMS- CoPS, and Joint Commission. Additionally, the team provides subject matter expertise in quality and data analytics, improvement, regulatory readiness (measures, dashboard and analysis); Supports councils and clinical care redesign initiatives. Coordinates the processes of monitoring, measuring and assessment of patient care and support systems to achieve high quality, safe, cost effective healthcare.

The System Director of Quality and Safety is an inspiring leader who provides strategic operational insight to serve the community; engage staff, providers and patients in fostering quality, safety, innovation, and continuous improvement. Works collaboratively with senior leaders, clinical department chairs, risk management, employees and administrative leadership to develop and implement the system and hospital’s quality and safety program and to ensure regulatory compliance and accreditation

Essential Job Functions and Responsibilities:

  • Highly visible, energetic champion of Quality and performance improvement across the BHHCG organization with specific focus on Bristol Hospital.
  • Works closely with organizational leadership to improve safety, Quality, efficiency and effectiveness through the application of the Malcolm Baldrige criteria, appropriate PI methodologies and in support of the nursing Magnet program.
  • Also participates/supports organizational committees, teams, and projects for BHHCG related to all aspects of performance improvement and the optimization of patient outcomes, for example, Patient Safety, Infection Control, Patient Experience, and Quality & Credentialing
  • Oversees the Coordination of the high reliability process, serious safety event team and root cause analyses related to clinical performance improvement and patient safety.
  • Process Improvement
    • Assures quality data is being collected and distributed to appropriate committees, departments and individuals.
    • Promotes culture of accountability to achieve goals reflected by metrics outlined in the QI Plan
    • Coordinates the processes of monitoring, measuring and assessment of patient care and support systems to achieve high quality, safe, cost effective healthcare services.
    • Oversees abstraction and data collection of all Core measures and other federal/state regulated data.
    • Engages all disciplines and levels of the organization to ensure efficient and effective improvement actions are implemented.
  • Provides BHHCG leadership with quality trends, analysis and process improvement activities that drive work for clinical improvement. Develops quality overview and analysis of trends/activities for the Chair of the BHHCG Quality Improvement committee of the Board of Directors. Coordinates the annual review and revision of the hospital Performance Improvement and Patient Safety Plans for approval by the Board of Directors.
  • Serves as the expert on hospital-wide regulatory standards for Joint Commission, DPH and CMS compliance
    • Facilitates/strategizes and monitors action plans specific to federal and state regulations.
    • Shares information with Organization Leadership based upon the above standards
    • Monitors compliance with Joint Commission, CMS and Department of Public Health standards.
    • In collaboration with Department leadership, investigates and reports adverse events to DPH, Joint Commission as appropriate. Oversees monitoring, and implementation and completion of action plans.
    • Interprets hospital performance improvement assessment policies and procedures to the organization.
    • Provides oversight and manages the performance of the Quality Performance Improvement staff, including delegation of responsibilities for department or committee-specific support functions.
  • Serves as a sponsor for specified performance improvement teams, and serves as an “expert resource” for facilitation and training. Supports ongoing peer review and ongoing professional practice review process.
  • Assists managers and clinical chiefs in the development, prioritization and implementation of department and division specific performance improvement, and peer review activities.
  • Through collaboration, develops and recommends best practices; oversees implementation of practices and programs. Identifies and recommends opportunities for improvement of services provided. Engages staff in process improvement and change activities. Encourages positive response to new opportunities, new technology and changes in healthcare.

General Leadership Responsibilities

  • Develops performance plan for all direct reports.
    • Develops, implements and manages the annual department budgets
    • Leads through example
    • Monitors results; provides coaching, counseling and direction as necessary; Reviews and evaluates staff at regular intervals
    • Provides training consistent with current and future job requirements. Functions as mentor/preceptor for staff members through lectures, hands-on demonstrations, and coaching. Foster an environment conducive to on-going learning and education.

Educational / Minimum Requirements:

Master’s Degree in Nursing, Health Administration, Management or related discipline.

Five to seven years + recent management experience in quality improvement in an acute care setting. Previous experience in regulatory and Joint Commission accreditation process.

State/Federal Mandated Licensure or Certification Requirements:

Appropriate CT License consistent with training. CPHQ Certification is preferred.

Bristol Hospital Mandated Educational Requirements:

General orientation at time of hire. Fire/Safety/Infection Control annually. Other programs as mandated by Hospital.

Special Requirements:

  • Knowledge of federal and state regulatory requirements.
  • Highly effective analytical, organizational, and problem solving skills.
  • Excellent written and verbal communication skills.
  • Adherence to BHHCG WE CARE values
  • Strong facilitation skills.
  • Strong knowledge of performance improvement methodologies and statistical process control tools.
  • Able to interact fluidly with staff at all levels within the organization, from front-line to senior leadership.
  • Skill in planning, organizing and delegating departmental responsibilities.
  • Skill in coaching, counseling, developing others. Ability to analyze and solve problems.Consistently demonstrates caring for patients, for one another, and for the organization they are part of, and contributes to building trust, pride and camaraderie
  • Maintain currency in knowledge, skills, and credentials through participation in seminars, conferences and other educational opportunities

Physical Requirements:

Work Environment:

Normal office conditions.

Cognitive Requirements:


The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities from time to time, as needed.




Masters or better.