Director of Quality and Patient Safety

Creating Life Better Here starts with you. At San Juan Regional Medical Center, we're more than a healthcare provider—we're a values-driven organization dedicated to delivering exceptional care. As a team member, you help fulfill our mission to make life better here for our community.The Director of Quality and Patient Safety serves as a highly visible, energetic champion of quality and performance improvement throughout San Juan Regional Medical Center (SJRMC) and San Juan Health Partners (SJHP). This role reports to the Chief Medical Officer (CMO) and works closely with senior leadership, providers, and all staff to continuously improve patient safety, quality, quality data metrics, as well as health system operations. The Director of Quality is a key contributor in developing a comprehensive system wide program to minimize patient harm through systematic organizational improvement and implementation of systems that create a culture of safety, proactively identify harm, encourage adverse event reporting, and supports thoughtful, learning-oriented analysis of safety trends and patterns. This role also facilitates decision support for teams and individuals at all levels and in all departments. Under the direction of the CMO, this role develops, directs, and leads the Organizational Excellence (Performance Improvement), Quality Management Systems, Patient Experience, and Infection Control teams. Through leadership with an emphasis on organization systematic improvement, the Director propels data into meaningful system-wide change.RequiredBehaviors:As you go about fulfilling this mission, your work habits and work relationships should embody SJRMC's values. These values are our culture, our identity as an organization. Sacred Trust, Personal Reverence, Thoughtful Anticipation, Team Accountability, and Creative Vitality ask more of us than merely completing some list of tasks. Our values ask for a deeper level of commitment, and what is asked of us we freely give because we believe in our mission.RequiredQualifications:Bachelor’s degree in healthcare (or related field) or ten or more (10+) years of healthcare experience with prior experience working within a hospital setting, quality-focused organization (NQF, NCQA), a provider association or society, academia, consulting firm or combination of education and experienceAt least five (5) years’ experience in progressively increasing leadership positionsCPHQ certification or equivalent in one (1) year.Strong knowledge of LEAN/Six Sigma methodologies, obtaining Black belt or equivalent within three (3) years of hireExperience in quality data measures, databases, scorecards, analysis of data, and communication of data into meaningful informationExperience as a quality subject matter expert within a team and across an organizationPreferredQualifications:Master’s degree, other certifications in healthcare qualityDeep knowledge of Performance Improvement methodologiesDeep knowledge of CMS Quality Measures, Scorecards, data analysis, and data roll-up methodologiesWorking knowledge of MACRA, report writing, Risk/Harm Assessment, Provider Peer Review, HIM, CDI, CM, patient safety and codingDuties and Responsibilities:Use data-driven focus that sets priorities for improvements that are aligned with organizational goals and strategic planOversee Performance Improvement and LEAN/Six Sigma projects and providing guidance to the entire systemManage quality contractsManage team effectively in a rapid-changing and ambiguous environmentChampion for the organization’s culture of safetyDevelop the Quality Plan, budget, policies, and goalsPromote standard work, best-practice, and shared leadership in a CQI/TQM LEAN EnvironmentSubject matter expert in quality and performance improvementOversee accuracy and timeliness of Harm and Quality ScorecardsEnsure that the department operates within organizational frameworksClearly and concisely present information to leadership, public, and staff on all levelsSupport the MEC, Senior Leadership, and Board of Directors through accurate and consistent reportingRespond effectively and professionally to confidential inquiries, time sensitive requests, and high-risk topicsOversee all quality extractions, submissions, and reporting (i.e., core measures and scorecard) writing for quality initiatives, data roll-up, and Hospital Compare ReportingLead and manage the Quality Team including education, staffing, payroll, recruitment, team cohesion, coaching, counseling, and annual reviewsLead and direct all aspects of the quality program including strategic planning, goal setting, program development, and team functionsAnalyze, identify, and report issues or policies that have the potential to negatively impact clinical outcomes and/or the delivery of quality careCollaborate with the CMO to support the organization’s quality committees including Quality Council, QAPI and the Medical Staff Quality & Performance Improvement CommitteePerform other duties as assignedEach employee is responsible for implementing SJRMC’s Service Standards into their daily work:Safety, Courtesy, Effectiveness, and StewardshipPhysical Demands and Environmental Work Conditions:Moderate noise levelFrequent interruptionsProlonged sitting, standing, and/or walkingBalance fast pace and competing prioritiesDefine problems, collect data, establish facts, and draw valid conclusionsPrimarily office environment with daily inclusion in operational environmentsInterpret an extensive variety of technical documents in mathematical, narrative, or diagram form