JOB SUMMARY
Directs, controls and is accountable for Quality within their assigned facility or community; including PHMG.  Develop long and short-term business strategies, operational plans and oversees implementation.  Manage the design, structure, development and planning issues within scope of direction.  Responsible for quality, service and regulatory compliance for areas of responsibility. Demonstrate the Mission, Vision, and Values in the achievement of excellent clinical quality outcomes and   improved results in the Triple Aim (improved individual quality, improved population health, and lower costs of care); In partnership with the facility CMO and System Quality VP, lead the Community quality agenda to reach top decile performance and outcomes ensuring community alignment with system goals. Coordinate and facilitate quality improvement teams with a focus on quality, safety, compliance and risk mitigation.  Responsible for Patient Safety and Regulatory requirements in local community, partners with PeaceHealth patient safety and regulatory staff to achieve.  

ESSENTIAL FUNCTIONS
1. In partnership with System Quality Vice President, leads the community inpatient and outpatient quality improvement initiatives to insure high clinical outcomes, improved patient safety, regulatory compliance and enhanced patient experience.   Lead clinical quality improvement in collaboration with the Chief Medical Officer, Community Quality Committees, Medical Staff leaders, Clinical Operations, and frontline staff.     

2. Serves as chair for Quality Management Committee and supports other quality committees provide consultation to clinical quality improvement teams.  Responsible to allocate Network/Community quality, safety and process improvement resources to achieve goals.  

3. Leads implementation of PeaceHealth Quality Plan Supports System CNO & CMO and community senior leaders, in preparing ongoing performance reports to the Community Quality Committee(s) and Board.    

4. Leads and supports managers, physician leaders, departments and staff to transform healthcare delivery to ensure patient engagement in providing care that is safe, efficient, effective, timely, and equitable.  Leads clinical teams to achieve highest quality outcomes.
5. Coordinates organizational strategies to enhance the alignment and implementation for optimum performance and patient outcomes; with a focus on the continuum of care delivery services.  
6. Manages flow of patient information, including the collection and reporting of clinical indicators and measures and adoption of clinical decision support functions.   

7. Actively support system approaches to clinical quality adopting system standards, shared learnings and implementing best practices.   
8. Manages accreditation surveys, partners with regulatory consultant to assure readiness for survey, monitoring of required metrics, corrective and preventive action planning as appropriate and follow-up after survey. Leads internal auditing at facility and subsequent action plans. In consultation with the Regulatory and Accreditation team, provides leadership to ensure compliance with regulatory, accreditation and licensure requirements
9. Works with the CMOs and the Patient Safety Coordinators in conducting a review of patient incidents, analysis, approvals of action plans and follow up monitoring. Uses best practice standards within health care environments; guides development of clinical risk reduction initiatives and methodologies. 

10. Partners with Process Improvement team to assure lean approach, with standard improvement methodologies and tools.  Facilitation of root cause analysis, Failure Mode and Effects Analysis and occurrence reporting management. 

11. Partners with medical staff leaders to align performance indicators to support peer review, physician performance expectations, and outcomes studies.   

12. Performs other duties as required.

QUALIFICATIONS

EDUCATION:     Bachelor's degree required in Nursing, Business or a healthcare related field. Master's degree required or a combination of education and professional experience that provides the incumbent with the requisite knowledge, skills and ability to successfully perform the job with the agreement to obtain within 3 years of date of hire. If a Nurse:  BSN or MSN required upon hire.

EXPERIENCE/TRAINING :    

    Minimum of 7 years in clinical quality improvement.
    Minimum of 5 years of management experience required.

LICENSE/CERTIFICATION     

    Certified Professional in Healthcare Quality (CPHQ) is required within two and a half years of hire.
    Maintain certification/licensure in clinical field.  

OTHER SKILLS:

    Ability to deliver financial results for areas of accountability.
    Must be able to lead successfully in a matrix organization. 
    Must demonstrate passion for continuous improvement; including skills in QI methodologies and tools.    
    Must have the ability to communicate to multiple audiences, prioritize and maintain perspective for organization's vision and quality. 
    Must have a strong understanding of tenants of ISO 9000.1 and knowledge of regulatory/accreditation and licensure standards
    Must be able to work effectively with multiple individuals/groups both internally and externally.  Must be able to challenge effectively at all levels and teams. 
    Demonstrates strong planning skill, and execute from a strategic level to a meeting level. 
    Must be able to manage staff.
    Displays optimistic, relationship and trust-oriented, forward looking and flexible approach.
    Knowledge of disease management/care management and utilization management