The Director, Quality is responsible to provide leadership in the development, planning and management of the organization-wide Quality Improvement program. Assure appropriate systematic monitoring and evaluation of the delivery of patient care for all departments, patient safety, infection control, patient satisfaction and continuous improvement in those clinical measures reports to external agencies.
• Strategically and operationally organizes, plans, directs and coordinates the integration of the Quality Improvement Plan throughout the Hospital. Assures that program goals and objective are met. • Establishes and maintains a written organizational Quality Improvement plan that supports a systemic, coordinated, continuous improvement approach to the delivery of patient care and services by all medical and hospital staff. • Assures that the plan meets the standards and requirements of governing bodies, review agencies and is consistent with the Mission, Vision, and Values of Main Line Health. • Provides an oversight and accountability to assure that Quality Improvement efforts are managed and reported according to the plan. Assures timely notification of significant quality issues through appropriately designated committee and administrative channels. • Assures appropriate action plans are developed, implemented, and monitored and demonstrates improvement. Provides reports as requested. • Assists with FMECA and root cause analysis and the implementation of subsequent action plans. Makes recommendations for teams and monitors action plans as they develop. • Provides oversight leadership to the Education, Telecommunications and Volunteer Departments. • Collaboratively identifies new opportunities to improve system processes and patient care/services and to reduce costs. • Monitors departmental improvement indicators for compliance with the organizational Quality Improvement plan. • Analyzes Quality Improvement data for accuracy, clarity, ease of use and relevance to current organizational strategies. • Makes informed recommendations for necessary resources needed to implement/ facilitate the quality improvement plan. • Assures hospital staff is competent to perform quality improvement initiatives. • Coordinates the Hospital's patient satisfaction measurement activities. • Maintains support and enforces strict practices of confidentiality in accordance with MLH, Federal and State laws and regulations. • Safeguards confidential patient-related information and records. • Acts as a resource and provides consultation to all Hospital staff in regards to quality improvement. • Attends JHS system meetings for clinical quality and performance improvement. • Leads selected system-wide quality initiatives. • Directs, maintains and facilitates the FIM/TSI data link and Utilization for Meaningful Outcomes. Directs, maintains and facilitates utilization of Press Ganey patient satisfaction data to enhance overall quality. • Provides direction and leadership for maintaining integrated Quality Management functions in the hospital, which meets TJC, CARF, state standards and regulations. Facilitates successful adherence and monitoring of compliance to regulatory standards. • Fosters a culture that respects the diversity and uniqueness of patients, staff and the communities MLH serves.
Education: • Bachelors in a healthcare field required; Masters in healthcare related field preferred.
Experience: • Minimum of 5 years healthcare experience, preferably within a rehab hospital. • Minimum of 5 years quality improvement experience, preferably in an acute care setting. • Minimum of 5 years management experience preferred.
Internal Number: ST-00034528
About Main Line Health
Founded in 1985, Main Line Health® is a not-for-profit health system serving portions of Philadelphia and its western suburbs. At its core are four of the region’s most respected acute care hospitals—Lankenau Medical Center, Bryn Mawr Hospital, Paoli Hospital and Riddle Hospital—as well as one of the nation’s premier facilities for rehabilitative medicine, Bryn Mawr Rehabilitation Hospital.