Executive Director - Clinical Quality - Miamisburg - FT/Days - Kettering Health

Overview

Kettering Health is a not-for-profit system of 13 medical centers and more than 120 outpatient facilities serving southwest Ohio. We are committed to transforming the health care experience with high-quality care for every stage of life. Our service-oriented mission is in action every day, whether it’s by providing care in our facilities, training the next generation of health care professionals, or serving others through international outreach.

Responsibilities & Requirements

JOB SUMMARY:Provides focused leadership for Clinical Quality and Patient Safety across the system to ensure delivery of theright care, to the right patient, at the right time. Ensures KHN alignment of workflows and performanceimprovement initiatives to create one best practice based on national standards.Responsible for the Quality Programs related Inpatient and outpatient care. Serves as a dyad partner with theSystem Patient Safety Officer to develop and implement strategies for a comprehensive Patient SafetyProgram including identification and deployment of best practices and a measurement system to monitorperformance. Serves as the System Point of contact for the Patient Safety Organization.Provides strategy and oversight for management of mandated data reporting requirements including CMS,Cardiac Registries (STS Adult Cardiac Surgery, NCDR PCI, ICD, Peripheral Vascular, Atrial Fib Ablation, Left AtrialAppendage Occlusion and STS/ACC Transcatheter Valve Replacement and Repair procedure), and stroke.Develops strategy and oversight of plans and data management related to infection control and as well asdata management related to requirements for National Healthcare Safety Network (NHSN).Creates strategies and workflows that support achievement of top decile performance in quality and patientsafety measures related to publicly reported entities and payer scorecards including Anthem, UHC, Top 100,and healthgrades. Responsible for strategy and deployment of the System’s approach to accreditation for hospitals includingHFAP accreditation and other accrediting/certification and accrediting requirements. Serves as the lead for theQuality Section of HFAP. Oversees the annual QAPI plan and Patient Safety Plan. Oversees and facilitates theSystem peer review process. As part of the multidisciplinary team, this Executive Director collaborates with the quality leadership across the system and other organization leaders to support system wide quality objectives and goals.

JOB REQUIREMENTSMinimum Education:• Bachelor’s Degree in nursing• Master’s Degree in Nursing or Healthcare Related Field• Certified Professional of Healthcare Quality – required or must be willing to obtain within 3 yearsMinimum Work Experience• Five (5) years of progressive supervisory experience with demonstrated leadership and management skills• Maintains competencies & skills of specialty area of practice. Ability to communicate effectively, written andoral.

Required Licenses:

Registered Nurse• Licensed as a Registered Nurse by the State of Ohio• Certified Professional of Healthcare Quality – required or must be willing to obtain within 3 years Required Skills• Skills of specialty area of practice• Ability to communicate effectively, written and oral

ESSENTIAL FUNCTIONS:Provides System leadership on strategic quality and patient safety strategies and performance, leading to Topdecile performance.2. Monitors performance against payers and publicly reported entities to identify key priorities. Including butnot limited to Leapfrog, Top 100, Anthem, UHC, VBP, HAC reduction)3. Develops strategy and provides guidance and support to the Infection Control Program across KHN.4. Develop strategic plans for department, utilizing continuous quality improvement process in developmentof goals and action plans.5. Oversight of development and monitoring of key metrics to ensure compliance with National QualityInitiatives, registries and required reporting.6. Ensures timely submission of data to meet System obligations for mandatory reporting requirements.7. Utilizes data to identify priorities to support achieving top decile performance8. Oversight of System approach for HFAP and other regulatory/accreditation requirements to ensure fullaccreditation of each hospital and service.9. Serves as the lead for the HFAP quality requirements including chapter owner, QAPI review and plan, andNetwork Patient Safety Plan.10. Serves as System Administrator for multiple programs both internal and external including: Quality Net,NHSN, Cardiac Care and the Patient Safety Organization.11. Serves as co-chair and facilitator for the System Infection Control Steering Committees.12. Collaborates with KHN Clinical Quality campus leadership to align processes and deployment of qualityimprovement initiatives to achieve One Best Practice.13. Develop, monitors and guide Clinical Outcomes Department with annual plans and budget management14. Demonstrates current knowledge of and ability to operationalize nationally recognized quality initiatives,trends and issues related to areas of responsibility.15. Actively participates in meetings across network to support performance improvement activities andinitiatives. Serves as facilitator when appropriate.16. Demonstrates competency through the successful completion of job specific requirements includinganalytical, problem solving and conflict resolution skills.17. Provides oversight support to the campus directors / department managers for Infection Prevention andControl and Patient Safety.18. Develop and monitor the Network approach for peer review.19. Collaborate with Service Line leaders to align and develop quality metrics for employed physicians andpractices.20. Create an environment of participation and collaboration along with effective communication with keyinternal and external stakeholders.

LEADERSHIP CAPABILITIES:1. Develop annual budget in partnership with finance2. Ability to develop and present effective and engaging presentations for various audiences3. Effectively lead and manage direct and indirect reports4. Effectively build skillsets of direct and indirect reports5. Effective mentorship of others in the organization6. Professional and effective collaboration with multiple service lines in the organization and externally withvarious community services and health care delivery partnerships

ORGANIZATIONAL EXPECTATIONS:New Hire/Competencies1. Applies medical ethics to healthcare relationships2. Practices the Five Healing Presence Practices3. Demonstrates Infection control Behaviors