Director of Quality Improvement, Behavioral Health

The Corporate Director of Quality Improvement [CDQI], Behavioral Health [BH] works as part of the corporate quality team to ensure proper planning, organization, leadership and implementation of quality and clinical outcome strategic initiatives.

This team member will lead corporate wide projects aimed at improving quality and clinical outcomes, including publicly reported measures.

The CDQI for BH provides leadership, expertise, education, guidance, and assistance to CHS-affiliated organizations, Regional leaders, Corporate Leadership, and Corporate departments to support quality improvement projects that have been prioritized in the quality agenda for the organization.

Essential Functions

• Plays a key role in organizing quality and clinical operations staff to accomplish organizational quality, patient safety, and regulatory/survey management goals.
• Collaborates with senior leadership and service-line departments to implement processes that will improve quality / clinical outcomes, prevent patient harm and maintain regulatory compliance..
• Support the Senior Quality and Clinical Operations leadership with focused analyses or improvement efforts and management of quality improvement / performance improvement projects and initiatives.
• Ability to manage / lead a variety of quality improvement projects and initiatives.
• Corporate-wide leadership of quality improvement efforts related to publicly reported data and outcomes, [CMS Programs, the Leapfrog Hospital Survey, the Leapfrog Safety Grade, and managed care quality measure initiatives] including coordination, education, submission of data, internal reporting, and improvement initiatives.
• Ensure mechanisms are in place to assess progress towards implementation of BH quality improvement goals and objectives.
• Lead company-wide, group, regional, and/or facility education programs and resource materials for specific quality improvement projects.
• Expertise with the CHS Process Improvement methodology.
• Assist the organization to plan, implement, and evaluate the effectiveness of improvement efforts.
• Support "Continuous Survey Readiness" across the behavioral health service line by working collaboratively with the survey readiness team. providing strategic collaboration for all behavioral health related deficiency remediation and collaborating with clinical leadership to integrate corrective actions into daily workflows to promote permanent compliance and ongoing success.
• Develop orientation and education programs for new hospital quality leaders and other applicable staff, and provide on-going education / support specific to behavioral health quality improvement and regulatory standards.
• Coordinate efforts with other internal CHS support departments to support achievement of individual / hospital/regional/corporate goals.
• Provides oversight and development of policies and procedures that support quality and clinical outcome improvement, including providing input to policy and procedure reviews to ensure all policies are up-to-date and reflect evidence-based principles and practices.
• Routinely communicate effectively with facility/regional/department/corporate leaders on findings, priorities, results of improvement actions, barriers to improvement actions, recommendations for improvement, and other pertinent information.
• Direct supervision of staff within the assigned area of responsibility.

Qualifications

• Bachelor's Degree in Nursing or other clinical healthcare field required
• 7 years current experience in Healthcare Quality with at least 3 years recent experience in quality management, performance improvement, outcome improvement and patient safety required. 3 years recent experience in behavioral health leadership.

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure required
• CPHQ - Certified Professional in Healthcare Quality obtained within two (2) years of hire required