Director, Quality and Enterprise Clinical Effectiveness

Job description

Purpose:
At UConn Health Waterbury Hospital this position is accountable for management of Quality. The role is the operational quality strategist, system wide improvement architect and change management leader.
Reporting Relationship:
Reports directly to President of UConn Waterbury Hospital and has a matrix reporting relationship into the COO/CNO of UConn Health John Dempsey Hospital.
Supervision Responsibility:
Directs, mentors, coaches, and manages staff within areas of responsibility.
Principal Duties and Accountabilities:
Operational Performance
• Serves as a liaison with the senior team in planning strategic goals and objectives, implementation and evaluation of operations and clinical outcomes.
• Conducts regularly scheduled meetings with the departmental leaders to address goals and objectives, operational performance, and improvement strategies.
• Ensure the safe and compliant development and maintenance of objectives, policies, and procedures.
• Assures departmental goals and objectives are established to ensure the institutional goals are met.
• Recommends and/or participates in the development of policies and procedures as applicable.
• Develops, implements, and evaluates performance improvement plans in response to opportunities in patient care areas, and assures patient safety outcomes.
• Owns the organizations quality data analytics and visualization of results including Development of dashboards, Statistical process control charts, Benchmarking against Vizient, Leapfrog, CMS, Press Ganey, NHSN, etc., Trend analysis and predictive modeling, Data transparency to frontline leaders.
• Drives HRO leadership that includes but is not limited to Safety culture transformation, HRO principles, Daily safety huddles, Error prevention tools, Behavioral accountability, Just Culture implementation.
• Serves as a network liaison and internal consultant regarding our medical group quality oversight, Population health metrics, Readmissions reduction, Care transitions, post-acute coordination, and value-based care metrics.

Financial Performance
• Develops and oversees the preparation and monitoring of the responsible department’s annual personnel, supply, and equipment budgets.
• Monitors budgetary variances and progress in budget performance and makes necessary adjustments as needed.
• Hires, educates, mentors, and evaluates personnel.
• Makes recommendations and provides opportunities for growth and development of personnel and arranges for appropriate education and training.
• Ensures succession planning for own role as well as roles within area of responsibility.
• Promotes a level of professionalism, which motivates academic pursuit and continuing education on the part of the staff by establishing and meeting departmental based educational goals.
• Creates and maintains a supportive, continual learning environment for all staff, and students.
• Ensures annual performance evaluation of staff are completed timely.
• Responds in a timely fashion to staff concerns and functions proactively to maintain staff engagement.
• Demonstrates self-development and keeps current in a variety of quality, regulatory, patient support, and health care topics by participation on a national and local level in professional associations.
• Attends national and regional meetings and conferences pertaining to quality programs.

Quality
• Assists with assuring continual compliance of responsible departments with The Joint Commission, Department of Public Health, Centers for Medicare & Medicaid Services, Public Health Law, HIPAA, Corporate Compliance, institutional and departmental rules, and regulations and makes certain these are properly addressed in policy and procedure.
• Actively participates in relevant committees of the Connecticut Hospital Association.
• Collaborates with the Chief Nursing Officer and others as applicable to establish standards and evaluates overall compliance.
• Ensures that a safe environment is maintained for all department staff.
• Fosters and implements programs within the departments that support cultural diversity.
• Knowledge of publicly reported measures the process, implications, and projections including but not limited to: CMS Star Ratings, Leapfrog, Hospital Compare, Healthgrades, US News participation, Vizient rankings.
• Accountable for demonstrated improvement over time in hospital-acquired conditions, mortality reviews, readmissions, length of stay collaboration, throughput metrics, and patient experience integration.
• Infection Prevention integration that includes HAI reduction strategy, infection prevention oversight collaborations, antibiotic stewardship participations and NHSN reporting.

Interactive Relationships
• Promotes empowerment of the departmental staff by utilizing collaborative approaches and encouraging innovative ideas.
• Functions as a leader in support of the healthcare team and various interdisciplinary committees to improve patient care and meet patient needs.
• Promotes collegial relationships based on mutual respect and support at all levels of the nursing organization.
• Coaches, counsels, and disciplines employees; plans, monitors, and appraises job results; develops staff by providing information, educational opportunities, and experiential growth opportunities.
• Collaborates with Medical Director on improving patient outcomes. Engages physician in partnership regarding quality initiatives, clinical variation reduction, peer review collaborations and physician scorecards.

Knowledge, Skills & Abilities:
Considerable knowledge and ability to apply management principles and techniques; considerable knowledge of relevant federal, state and regulatory agencies regulations and risk standards; ability to establish strong working relationships with physicians and staff at all levels, considerable communication (oral and written) and interpersonal skills; ability to analyze problems quickly and effectively resolve issues; effective leader comfortable with autonomous decision making under stressful conditions, strong organizational and time management skills. Effective use of technology and AI.
Experience and Training:
Bachelor’s and/or master’s degrees required.
Special Requirements:
• Minimum of eight (8) years nursing experience with five (5) years progressive experience in the field of Nursing, Quality or Analytics
• Five (5) years’ experience as a clinical leader.
• Must have and maintain a current license as a registered professional nurse in the State of Connecticut.
• Any one of the following is preferred: CPHQ, Lean Six Sigma, CPPS certification.