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*Greenbelt in process improvement methods or equivalent with 5 years of experience leading improvement or system design projects required

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Reports to:

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VP of Hospital Based Ancillary Services within a highly matrixed relationship with the Chief Nursing Officer, Chief Medical Officer and Chief Executive Officer

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Position Standards:

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Master's degree and 5 years of related clinical supervisory/management experience required. Candidates matriculated into a Master's program will be considered

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Clinical Profession licensure in NH required; Licensed Registered Nurse in New Hampshire preferred; will consider other clinical areas of licensure.

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Greenbelt in process improvement methods or equivalent with 5 years of experience leading improvement or system design projects required

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Excellent organizational, interpersonal, oral and writing skills required

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Exemplary leadership qualities

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Prior experience with budgetary preparation and systems development required

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The ability to relate and deal effectively with physicians, administrators, support staff, board members and the general public with a high degree of tact and discretion required

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Ability to develop and present effective presentations to varying audiences across multiple disciplines at all levels of the organization and system

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Working knowledge of statistics and Statistical Process Control

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Expertise in POWERPOINT, WORD and EXCEL

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Expertise in ACCESS or other database programs desired

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Ability to make independent decisions in judgment using general guidelines provided by leadership

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Familiarity with CMS Conditions of Participation, State and Federal Regulations

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Position Physical Requirements:

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Anything listed here requires a pre-employment physical by Employee Health to determine if the employee is capable of meeting the requirements.

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Physical Activity:

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Upper Extremity:

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Ability to stand and/or sit for long periods of time.

Mobility is essential

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Push/Pull/Lift/Carry:

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Part Two: Performance Expectations - Director

* Patient Focus: Places, first and foremost, the quality of the care and safety of the patient/resident first. Does the right thing for the patient and resident. Maintains disciplined attention to quality, cost and access.

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Knowledge of Profession:Demonstrates comprehensive, current skills and knowledge within area of expertise.

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Respects Rules/Recognizes Boundaries:When going outside own realm of expertise and responsibility, in the service of improving current rules and processes, seeks other's knowledge and ensures the regulatory well being of APD. Respects established organizations rules and accreditation regulations.

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Human Resource Management:Maintains responsibility for the hiring, orienting, development, and recognition of departmental staff. Manages the performance of staff in accordance with Human Resource Policies.

- Define and document expectations for all direct reports.

- Grow and develop employees

- Maintain positive and collaborative relationships with members of the medical staff

- If challenges arise, partner with VP and HR to initiate, implement, and document improvement plan.

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Financial Stewardship:Plans and adheres to departmental budget. Identifies and takes action on opportunities for cost savings and revenue growth.

- On a monthly basis, review organization's volumes and department expense budget.

- Adjust departmental expenses in proportion to volume variances.

- If leading a clinical department, ensure accurate and complete charge capture and coding.

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Policy Management:Maintains, communicates updates, and enforces departmental policies. Keeping at the forefront, regulatory compliance, quality of patient/resident care and evidence based best practice.

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Confidentiality/Privacy:Follows and ensures staff compliance with APD policies regarding privacy and confidentiality. Remains informed and knowledgeable of HIPAA. Attends all required training.

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Quality/Performance Improvement:Ensures departmental team participation in quality assurance and performance improvement processes. Responsible for ensuring compliance with CMS conditions of participation and other governing bodies for standards of care, where applicable.

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Part Three: Performance Expectations - Functional

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Plans, directs and overseas operations for Quality, Patient Safety, Infection Prevention Process Improvement and Patient Relations in partnership with physician and nurse leaders

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Provides oversight for the Patient Relations department, including review of potential risk concerns, and assists as needed with other related activities

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Ensures hospital compliance with Critical Access Hospital (CAH) required appendices and Centers for Medicare & Medicaid Services (CMS) standards related to clinical quality assurance/performance improvement activities. Coordinates efforts to comply with all other regulatory agencies related to quality practices.

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Assists and supports managers to develop/maintain appropriate policies, procedures, and documentation to fulfill requirements and regulations.

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Coordinates all quality improvement, quality assurance and performance Improvement activities throughout the hospital and hospital-owned clinics using evidence based proven methodologies such as lean/six-sigma.

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In conjunction with the senior administrative leadership, develops actionable quality metrics and design data collection methodologies.

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Designs and leads the implementation of improvement projects at all levels of the organization.

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Promotes the mission, strategic imperatives, and goals of the organization (APD and Dartmouth Health) and maintains a functional communication network and collaborative culture for effective customer service, teamwork, culture of quality and safety and system performance.

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Serves as an expert resource, mentor and coach to all departments regarding improvement activities and supports the training and education of staff in using a standardized approach to process improvement across the organization.

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Uses statistical analytic techniques, analyzes data for trends to identify improvement opportunities and assess the organization for system vulnerabilities, to facilitate appropriate improvement activities.

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Assembles and disseminates identified quality reports to all levels of the organization. Presents data in a clinically relevant manner to all stakeholders.

* Applies advanced skills in change management to maintain and promote a harmonious work environment across departments to assure alignment on clinical quality and safety projects.

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In collaboration with Risk Management, coordinates the management of clinical adverse event investigations (to include RCA/ACA), risk assessments and follow up on corrective actions as required by regulators, hospital policy or at the request of senior management using best practice, industry standard methodologies.

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Oversee all aspects of the organizations Culture of Safety plan including sentinel event reporting, RCA’s, system review and other investigation processes.

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Applies clinical knowledge in formal and informal consultation with individual staff and clinicians, managers, committees/teams and Risk Management to identify and address clinical quality and safety concerns. Chairs the APDMH Quality Committee meeting including the coordination of agendas and minute

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Responsible for the annual review of the Quality Assurance and Process Improvement (QAPI) program to include the development, review and annual update. This includes the development and dissemination of the QAPI Annual Report, Structure and Function and QAPI Workplan,

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Serves as hospital liaison, representative to NHHCQA Commission, and other outside committees as assigned participating with initiatives and projects as appropriate.

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Attends and participates in the DH Enterprise System Quality meetings and associated activities. Serves as a liaison to APDMH to communicate and facilitate implementation of DH Quality system level priorities. Works closely with DH System Quality Leadership.

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Encourages team spirit and enthusiasm in the staff by demonstrating a positive attitude and an ability to work with others in cooperative effort to ensure customer satisfaction and Continuous Quality Improvement.

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Performs other duties as assigned

* Area of Interest:Management/Executive;

* Work Status:Vary;

* Employment Type:Full Time;

* Job ID:5551

Dartmouth Health is an Affirmative Action and Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability.

Dartmouth Hitchcock Medical Center and Dartmouth Hitchcock Clinics comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. We do not exclude or treat people differently because of race, color, national origin, age, disability, or sex.