Job Description

JOB SUMMARY:
The Director Quality - West Region serves as a highly visible champion of quality and safety throughout the West regional hospitals and Trillium Place, a not-for-profit organization for Behavioral Health Services an affiliation with Carle Health. This role works closely with the region's President, President of Trillium Place, Chief Medical Officer, Chief Nursing Officer, and Executive Directors to provide leadership for system-wide efforts to continuously improve the quality and safety of care. This position leads the organization to achieve outstanding performance on key nationally standardized metrics of quality and safety. This position directs, plans, and implements the Performance Improvement Plan, the Patient Safety Plan, Accreditation and regulatory compliance efforts.

EDUCATIONAL REQUIREMENTS

• Bachelors degree, Nursing or
• Master's Degree in Nursing, Healthcare Administration or Business Administration (preferred)

CERTIFICATION & LICENSURE REQUIREMENTS

• Registered Professional Nurse (RN) License Illinois upon hire.
• CPHQ Certification within 1 yr. of hire

EXPERIENCE REQUIREMENTS

• Five (5) years of experience in/with prior experience which demonstrates clinical and leadership competence. And

SKILLS AND KNOWLEDGE

• Excellent understanding of current trends and issues in the professional practices of multiple disciplines.
• Successful performance of the position's accountabilities requires effective leadership skills
• Ability to prioritize multiple demands, and in-depth patient care knowledge.
• Outstanding listening, interpersonal relationship building, and problem-solving skills

• Exceptional level of professionalism, discretion and the ability to work on highly sensitive and confidential projects
• Able to prioritize and manage multiple projects simultaneously
• Demonstrated ability to complete projects successfully on time and within budget
• Knowledge of current trends and best practices in healthcare quality improvement and patient safety
• Highly developed skills using personal computer tools including MS Office

ESSENTIAL FUNCTIONS:

• Develops the organizational Quality/PI plan steps
• Implement plan across the organization to assure a systematic, consistent approach to PI across the continuum.
• Develop and implement strategies to integrate quality management plan and indicators within the organization
• Facilitates reporting of performance improvement activity through a variety of channels including Leadership Team, Clinical Council, Medical Staff Departments/Committees, etc.
• Evaluates quality and patient safety indicators in appropriate steering committees, departments, councils, etc.
• Serves as educator, facilitator, and internal quality consultant to the Board, Executive team, Quality Council, Medical Staff, clinical implementation teams and departments throughout the region.
• Collaborate with leaders and clinical staff to develop, implement, monitor, and champion performance improvement processes and policies related to key patient safety issues.
• Oversees the collection and dispersion of information related to patient safety through monitoring and reporting performance relative to patient safety indicators.
• Fosters a culture within Carle Health and Trillium Place that promotes prevention, detection, and resolution of conduct that does not conform to established standards, regulatory requirements, and ethical and business policies.
• Directs, plans, and coordinates organizational wide compliance with current standards of DNV, TJC, IDPH, SUPR, BOP, and other regulatory bodies to ensure ongoing compliance or active progress towards compliance; serves as primary contact.

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