VP of Quality Management

The VP of QM and Accreditation is responsible for planning, developing, and implementing Performance Improvement initiatives.  He/she provides education and leadership on a facility-wide, multidisciplinary level for Operational/Leadership Rounding, FMEA, Six Sigma, and Lean Projects; collects and performs analyses of key performance measures and hospital wide data; leads the department heads in quality performance initiatives and activities in compliance with regulations and organizational mission and goals.  The VP directs the performance improvement activities associated with The Joint Commission standards; is responsible for the hospital-wide laboratory Joint Commission accreditation surveys; performs all functions of The Joint Commission Priority Focus Chair for Improving Organizational Performance and responds to evidence of standard compliance issues and complaints to The Joint Commission.  He/she provides oversight and coordination of data registries for the service lines in the hospital.  This position oversees the Quality Management Department personnel and activities and may include other tasks and responsibilities as assigned by the CMO to meet the needs of the organization.

• Comprehends and uses data for the analysis of PI results.

• Shares comprehendible reports in a timely fashion.

• Plans and develops policies, and processes for policies and forms.

• Works to develop meaningful PI measures for Clinical Contracts as well as monitoring performance data from those contracts.

• Represents GSHMC as appropriate to CHS and LIHN in the areas of Quality Management.

• Works with Director of Q.M and the Q.M. Staff in developing and sustaining PI projects to address the benchmark data from LIHN, Joint Commission CMS and DOH Measures and as well as other sources.

• Administers and oversees the auditing and entering of data into Registries.

• Administrator for the Adult Cardiac Surgery program, American College of Cardiology NCDR and the Transcather Valve Therapy (TVT). 

• Reports quality, performance improvement and contractual data to the CHS corporate Quality Meeting Committee.

• Directs the organizational preparation and reediness of the hospital and laboratory for Joint Commission accreditation.

• Leads the organizational Leadership/Operational Rounding and staff education on PI process such as PDSA.

• Oversees hospital wide Joint Commission Disease Specific Certifications and associated surveys.

• Directs the overall functions of the QM department.

• Develops and administers procedures for the systematic review and evaluation of the QM staff.

• Develops, updates and reviews policies and procedures for the department.

• Interviews and hires for appropriate staff positions.

• Remains current with H-CAHPS literature and communications.

• Serves as a root user for H-CAHPS reports.

• Recommends ways to disseminate patient satisfaction information.

• Analyzes trends in aggregate data and identifies strategies for improvement.

• Directs and develops facility-wide PI initiatives and projects utilizing PDSA, Lean, and Six Sigma.

• Demonstrates ability to move issues to resolution.

• Demonstrates the ability to communicate with all levels of staff in an effective and professional manner.

• Utilizes conflict resolution and negotiating skills to ensure timely resolution of issues.

• Serves as a resource person for staff, hospital personnel and physicians.

• Educates and coaches department directors in process improvement methods.

• Collaborates with department directors for the improvement of employee, physician and patient satisfaction.

• Organizational accreditation survey preparation and Joint Commission Function Chair for improving organizational performance.

• Accepts and performs other functions as requested by the CMO.

• Attends continuing education programs on-site and off-site.

• Maintains current knowledge of new hospital and departmental policies and procedures.

• Investigates and keeps current with trends and innovations in Quality Management design.

• Accepts and acts on constructive criticism.

• Maintains knowledge of current Joint Commission and CMS standards.

• Employee supervises and checks the work of staff.

• Employee is qualified by experience and/or credentials to prepare performance evaluations and competency assessments of staff.

• Provides leadership and direction in accordance with department goals and policies.

• Supports administrative decision and changes within the department.

• Supervises the training of new employees.

Education: 

Master’s Degree and or 5 years of experience in a healthcare setting.

Experience:

At least 5 years of administrative/clinical management experience.  Minimum of 5 years Quality or Performance Improvement experience. Knowledge of Outlook, Work, Excel, Database and Power Point required.

Licensure/Certification:

NYS Licensed Health Care Professional.  CPHQ and or CJCP strongly preferred.

Preferred Qualifications:

Excellent organization skills; detail oriented, credibility with physicians and professional staff, flexibility, dependability, problem solving ability, creativity, effective communication skills, data analytical skills, team building skills, ability to motivate, plan, organize and direct activities of others; must be flexible and able to work in stressful environment.

This range serves as a good faith estimate and actual pay will encompass a number of factors, including a candidate’s qualifications, skills, competencies and experience. The salary range or rate listed does not include any bonuses/incentive, differential pay or other forms of compensation that may be applicable to this job, and it does not include the value of benefits.

At Catholic Health, we believe in a people-first approach. In addition to the estimated base pay provided, Catholic Health offers generous benefits packages, generous tuition assistance, a defined benefit pension plan, and a culture that supports professional and educational growth.