DIRECTOR - QUALITY SERVICES

The Director of Quality Services provides leadership and oversight for hospital-wide quality improvement, patient safety, regulatory compliance, accreditation readiness, and infection prevention programs. This role collaborates with physicians, nursing leadership, ancillary departments, and executive leadership to ensure the delivery of safe, high-quality, evidence-based patient care while maintaining compliance with federal, state, and accrediting agency standards

The Director of Quality has oversight for the Quality Department, Patient Safety, Patient Relations, Regulatory Compliance, and Infection Prevention & Control.

• Graduate of accredited School of Nursing with BSN required and MSN preferred;

• Current, valid unencumbered OBN or multistate license to practice registered nursing pursuant to Section 4723.11 of Ohio Revised Code.

• Advanced educational and experiential qualifications with consideration of the following:
  • Minimum of 3-5 years clinical experience;
  • Understanding of the organization’s scope and complexity and the position’s responsibility;
  • Knowledge of the scope and complexity of the nursing care needs of the major populations served, as well as the culturally diverse and special needs of the population;
  • Certification – required for those meeting certifying agency eligibility requirements preferred; – move to Specific Addendum if Required for entity/department; and
  • Maintain membership in a professional nursing organization required.

• Proven experience in quality assurance/improvement programs and statistical analysis methodologies.

• Certified Professional Healthcare Quality (CPHQ) certification preferred.

• Must be computer literate to complete task(s) as required.

• Obtain and maintain current American Heart Association (AHA) training in Basic Life Support (BLS) utilizing Resuscitation Quality Improvement (RQI) is required.

• Demonstrates effective communication and interacts appropriately and professionally.

• Comprehensive knowledge of hospital accreditation and regulatory standards.

• Understanding of infection prevention principles and epidemiology.

• Knowledge of CMS Conditions of Participation and quality reporting requirements.

• Proficiency with quality improvement methodologies.

• Strong analytical and data interpretation skills.

• Experience with electronic health records and quality reporting systems.

• Excellent communication, presentation, and leadership abilities.

• Ability to manage multiple priorities in a fast-paced healthcare environment.

• Strong problem-solving and critical-thinking skills.

• Ability to influence interdisciplinary teams and drive organizational change.

• Must be organized, able to effectively prioritize tasks and resources while exhibiting appropriate time management skills.

• Proficient computer skills to complete tasks as required.

• Develops expectations for colleagues and fosters a culture of mentoring and coaching.

• Respects patients’ rights and responsibilities, demonstrates respect for the patients’ culture, language, customs, and beliefs, demonstrates the use of age-specific principles in communicating and educating patients, and serve as a patient and family advocate.

• Promotes and holds colleagues accountable to use HRO tools and tones for high reliability and is committed to workplace safety.

• Identifies key performance indicators, develops/implements strategies based on evidence-based practice to improve patient outcomes, and continually monitors metrics.

• Participates in the recruitment and selection process.

• Responsible for effective retention strategy at the department level.

• Completes colleague evaluations.

• Participates and promotes growth of professional development of colleagues.

• Holds colleagues accountable for completion of education, competency, and orientation.

• Participates in planning, forecasting, and meeting budget for assigned cost center(s) while explaining financial variances.

• Responsible for department budget and makes decisions for operational planning.

• Focuses on the day-to-day operations of the department.

• Responsible for staffing and scheduling of colleagues within their assigned cost center(s) and providing hands-on assistance or coverage as needed.

• Commitment to continued personal and professional growth, including career planning.

• Participates and provides input in strategic planning.

• Facilitates participation of staff in organizational and unit-based decision-making councils and/or committees.

• Must adhere to the RN job description and competencies.

• Lead the hospital's Quality Assessment and Performance Improvement (QAPI) program.

• Monitor, analyze, and report quality metrics, patient outcomes, and performance indicators.

• Develop and implement quality improvement initiatives using Lean, Six Sigma, PDSA, or other improvement methodologies.

• Facilitate Root Cause Analyses (RCA), Failure Mode and Effects Analyses (FMEA), and corrective action plans.

• Analyze clinical data to identify trends and opportunities for improvement.

• Prepare quality reports for senior leadership, Medical Executive Committee, Quality Committee, and Board of Directors.

• Support achievement of CMS Core Measures, Hospital Compare metrics, and Value-Based Purchasing goals.

• Promote a culture of safety throughout the organization.

• Monitor patient safety events and adverse occurrences, oversee event reporting systems, and lead patient safety investigations and action planning.

• Facilitate patient safety education for staff.

• Ensure compliance with standards established by regulatory bodies.

• Coordinate hospital survey readiness activities, lead mock surveys and accreditation preparation, and develop corrective action plans following regulatory findings.

• Oversee the hospital Infection Prevention and Control Program.

• Conduct surveillance of healthcare-associated infections (HAIs), monitor NHSN reporting requirements, compliance with CDC infection prevention guidelines, and Investigate infection outbreaks and implement mitigation strategies.

• Collaborate with Employee Health regarding exposure management and immunization programs.

• Health Caring Standards / Values:
  • Greet customers, visitors, and Colleagues immediately with a smile, warm greeting, and introduction, calling them by name if possible.
  • Exceed the expected and anticipate the unexpected by asking, “Is there anything else I or a fellow Colleague can do for you?”.
  • Always provide a comforting, timely, caring departure or discharge, and always say thanks for allowing us to serve.
  • Integrity, openness and fairness in all you do.
  • Teamwork.
  • Pride in the Department.
  • Individual creativity and Innovation.
  • Compassion and caring.
  • Maintain department and hospital standards and policies.

• Promotes Aultman RESPECT values to foster a healthy work environment, while maintaining an environment of fairness and inclusivity.

• Abide and engage in the Aultman Leadership Promise, ACE.
  • Act - Meet with staff monthly.
  • Communicate - Share information.
  • Engage - Include colleagues in change initiatives.

• Abide and engage in the Aultman Leadership Values.
  • Live our Mission - Demonstrate and support our mission and values in our day-to-day leadership.
  • Think Strategically - Understand and communicate the vision and strategy.
  • Lead with Integrity - Earn and give trust by being direct, truthful and admitting when wrong.
  • Expect Excellence - Focus, align and build effective teams by attracting and retaining top talent.
  • Inspire to Make a Difference - Set personal examples of good work ethic and motivation.
  • Achieve Success - Set goals and motivate the team toward greater commitment to those goals

Work eight hours a day. This unit requires 24/7 coverage.

Shifts are variable to volume of department. Rotation as needed.

Work weekends and holidays as assigned. Every other weekend and two holidays a year, in a group rotation

Hybrid/WFH schedule available

Lunch periods and breaks are coordinated with other staff members to maintain adequate floor coverage

Cross training in all areas in the department is required.

On call coverage is assigned to cover the department schedule

Staff may be assigned to different locations within the foundation

Travel within a “XX” mile radius is required

• 24/7 responsibility for unit/department(s).

• On call coverage will be assigned.

• Hours are variable to allow time to interact with colleagues on off hours/shifts.

• Subject to frequent interruptions and changes in priority of duties throughout the day.

Category II - Includes tasks that involve no exposure to blood, body fluids, or tissues, but employment may require performing unplanned Category I tasks. The normal work routine involves no exposure to blood, body fluids, or tissues by exposure or potential exposure may be required as a condition of employment. Appropriate protective measures will be readily available to every employee engaged in Category II tasks.

Demands

Frequency

Remarks

Lifting 0-10 lbs

Frequent 34-65%

Lifting 10-20 lbs

Occasional 10-33%

Lifting 20-35 lbs

Occasional 10-33%

Lifting 35-50 lbs

Occasional 10-33%

Lifting 50-75 lbs

Occasional 10-33%

Lifting 75-100 lbs

Occasional 10-33%

Lifting over 100 lbs

Occasional 10-33%

Forward Reaching

Continuous 66% of the day

Overhead Reaching

Continuous 66% of the day

Standing

Continuous 66% of the day

Walking

Continuous 66% of the day

Sitting

Continuous 66% of the day

Climbing

Continuous 66% of the day

Stairs/Ladder

Continuous 66% of the day

Bending/Stooping

Continuous 66% of the day

Twisting/Turning

Occasional 10-33%

Kneeling/Squatting

Occasional 10-33%

Crawling

Never

Pushing/Pulling 0-10 lbs

Frequent 34-65%

Pushing/Pulling 10-20 lbs

Occasional 10-33%

Pushing/Pulling 20-35 lbs

Occasional 10-33%

Pushing/Pulling 35-50 lbs

Occasional 10-33%

Pushing/Pulling 50-100 lbs

Occasional 10-33%

Pushing/Pulling over 100 lbs

Occasional 10-33%

Carrying 0-10 lbs

Frequent 34-65%

Carrying 10-20 lbs

Occasional 10-33%

Carrying 20-35 lbs

Occasional 10-33%

Carrying 35-50 lbs

Occasional 10-33%

Carrying 50-100 lbs

Occasional 10-33%

Carrying over 100 lbs

Occasional 10-33%

Grasping/repetitive sustained

Continuous 66% of the day

Fine motor coordination

Continuous 66% of the day

Vision: Near/Far/Color

Continuous 66% of the day

Hearing: ordinary conversation/other

Continuous 66% of the day