Director of Quality, Operations (Full-Time, Days)

SUMMARY The Director is a key leadership position within the Quality Safety Institute (QSI) at Rochester Regional Health System (RRH). Working under the direction of the Sr. Director, and in partnership with other leaders across RRH, this role supports the Quality and Safety strategic pillar to provide the highest quality care, free from preventable harm with best in-class service at the lowest cost. The role is crucial to leading and advancing our commitment to providing high-quality healthcare services. The Director will be responsible for coordinating and facilitating quality improvement initiatives, ensuring compliance with regulatory standards, and fostering a culture of continuous improvement within our acute care hospitals. The Director will utilize knowledge of clinical, epidemiologic, improvement science and the clinical quality literature to provide leadership in improving and achieving superior outcomes. This position provides leadership and direction to the Quality Specialists in advancing performance and coordinating quality and safety programs.

Job Title:

Director of Quality Department:

Operations Location:

Riedman Campus 100 Kings Highway South Rochester, NY 14617

United States of America Hours Per Week:

Full-Time 40 hours/week

Schedule:

M-F 8am-5pm

RESPONSIBILITIES

Quality Improvement Leadership & Strategy:

• Develop and implement a comprehensive clinical quality and safety strategy that aligns with the organization's overall quality goals and objectives.
• Aligns resources to drive performance improvement of required measures.
• Provides leadership, support and mentorship to clinical Quality professionals.
• Provides technical support for quality improvement activities of clinical departments and units, specifically providing improvement teams with the necessary tools and approaches to improve measures of quality and safety.
• Participates in the development and management of budgets to support the Clinical Quality Program and in prioritization of resource allocation.
• Responsible for coordination and standardization of all aspects of clinical quality, performance improvement, and process redesign across aligned business areas.
• Collaborates with stakeholders across the organization to develop an infrastructure and implement plans that focus on improving patient outcomes and ensuring clinical best practices.
• Participate in coordination and management of hospital board quality meeting agenda planning, meeting prep and facilitation.

Performance & Data Analysis:

• Establishes and monitors key performance indicators (KPIs) related to clinical quality.
• Coordinate with business leadership on development of annual QAPSPI goals.
• Coordinates data abstraction, extraction, analysis, and intervention for clinical quality measures.
• Use data-driven insights to recommend improvements.
• Prepare and present regular reports on clinical quality metrics to leadership.

Quality Metrics Monitoring:

• Tracks performance improvement initiatives to ensure that objectives are met and recommended actions are fully implemented.
• Oversees, and monitors metrics for externally reported quality programs.

Coordinates with business leadership for opportunities for improvement. (Leapfrog, CMS Stars, CMS P4P, Excellus

HPIP, QAPSPI

goals, etc.)

• Lead and facilitate standardization of program compliance and implementation for aligned business area quality improvement programs.

Regulatory Compliance:

• Coordinate with Quality Specialists and Office of Clinical Regulatory Compliance to ensure preparation and participation for accreditation visits.
• Provide support and guidance for unanticipated regulatory visits related to quality matters.
• Liaise with system regulatory and other relevant areas on ensuring appropriate internal audit planning and completion.

Training & Education:

• Foster the use of performance improvement techniques to achieve optimum results.
• Offer guidance, education, and feedback to staff regarding quality improvement efforts, processes, and techniques.
• Provide ongoing education to healthcare professionals on best practices and quality standards.

Continuous Learning:

• Stays updated on advancements, trends, and leading practices in healthcare quality and performance improvement.
• Other duties as assigned

REQUIRED QUALIFICATIONS

• Master's degree in healthcare administration, nursing, or a related field required.
• Minimum of 5 years of experience in healthcare quality and patient safety (or other relevant experience), with at least 2 years in a leadership role (or other relevant experience) required.

Required Licensure/Certification:

• Certification in quality improvement, safety, clinical risk management or equivalent (e.g., Certified Professional in Healthcare Quality - CPHQ, Lean, Certified Professional in Patient Safety - CPPS) required or must be obtained within three years of hire.
• For those with a BSN; valid NYS Registered Nurse License is required.

PREFERRED QUALIFICATIONS

• Doctoral degree is preferred.
• In-depth knowledge of healthcare quality improvement methodologies, regulations, and accreditation standards (e.g., DNV, CMS).
• Strong analytical and data interpretation skills.
• Excellent leadership, communication, and team-building skills.
• Excellent communication, interpersonal, and project management skills.
• Ability to work collaboratively and adapt to changing healthcare environments.
• Detail-oriented with a focus on continuous improvement.
• Demonstrates skills and experience in process improvement methodologies, project management and team building.
• High level of meeting management, computer, teaching and training, organization and time management abilities.
• High level of leadership/facilitation skills.
• High level of analytical ability necessary to identify and illustrate relationships among activities, recommend courses of action based on making choices among alternative and design recommended.
• High level of proficiency with Microsoft Excel and PowerPoint.

EDUCATION

BS (Required)

LICENSES / CERTIFICATIONS

PHYSICAL

REQUIREMENTS

S - Sedentary Work - Exerting up to 10 pounds of force occasionally Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met. For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements. Any physical requirements reported by a prospective employee and/or employee's physician or delegate will be considered for accommodations.

PAY RANGE

$100,000.00 - $135,000.00

CITY:

Rochester

POSTAL CODE

14617 The listed base pay range is a good faith representation of current potential base pay for a successful full time applicant. It may be modified in the future and eligible for additional pay components. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts. Rochester Regional Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex (including pregnancy, childbirth, and related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, predisposing genetic characteristics, marital or familial status, military or veteran status, citizenship or immigration status, or any other characteristic protected by federal, state, or local law. Rochester Regional Health is an integrated health services organization serving the people of Western New York, the Finger Lakes, St. Lawrence County, and beyond. The system includes nine hospitals; primary and specialty practices, rehabilitation centers, ambulatory campuses and immediate care facilities; innovative senior services, facilities and independent housing; a wide range of behavioral health services; and Rochester Regional Health Laboratories and ACM Global Laboratories, a global leader in patient and clinical trials. It's vision is to lead the evolution of healthcare to enable every member of the communities it serves to enjoy a better, healthier life.