“The delivery of exceptional patient care focusing on caring, quality, safety, and service.”
Overview
The director of clinical quality and performance improvement is responsible for direction, coordination, and oversight of clinical quality improvement, patient safety, patient experience, risk management, and performance improvement functions at Olmsted Medical Center. The director works in partnership with senior leadership, nursing, ancillary services, and department leadership to develop and implement a best-in-class performance excellence and patient safety program.
This role reports to our Chief Nursing Officer.
Responsibilities
Provides oversight for
Accreditation:
Coordinates system-wide accreditation readiness activities.
Oversees Baldrige readiness, quality measurement, ISO 9001, and Det Norske Veritas (DNV) accreditation, holding staff and departments accountable for achieving performance goals.
Provides guidance and support for local accreditation program; ex: trauma and rehab certification.
Establishes quality measurement and improvement activities, including methods to track implementation of action plans following site surveys and critical events reviews.
Infection control:
Oversees the infection control program in collaboration with the infection prevention nurse.
Partners with infection control practitioner to ensure the development and implementation of the infection control plan.
Utilization review and management
Patient safety
Patient relations
Medical staff function
Supports and assists in the development of a Peer Review Process as assigned by senior medical leadership
Provides resources and participates in nursing and physician peer review processes and chart reviews, as necessary
Facilitates development of the ongoing performance measures for the clinicians
Collaborates with clinical staff and operational leadership to envision, develop, and implement the organizations performance excellence (quality) and patient safety plan.
Focuses on healthcare value, including the improvement of clinical outcomes, patient experience, patient safety, costs, revenue, productivity, efficiency, employee and physician satisfaction, and process reliability.
Assures a common standard of care and service throughout the organization.
Develops, implements, and maintains a comprehensive quality management program that is compliant with the ISO 9001 standards and the Baldrige Performance Excellence Program.
Collaborates with other executives and engaging with leaders and clinicians throughout the organization in a hands-on fashion to build quality, efficiency, effectiveness, and a sense of shared accountability.
Develops programs to review and evaluate patient care and outcomes.
Engages staff at all levels as participants in a continual support of improvement opportunities.
Establishes quality measurement and improvement activities, including methods to track implementation of action plans following site surveys and critical events reviews.
Facilitates alignment between improvement initiatives and the organizations strategic plan.
Facilitates, develops, and implements special projects as assigned by senior leadership.
In partnership with clinical informatics, prepares and interprets reports, summaries, and statistical data including system-wide performance improvement summaries to identify trends and make recommendations for improvement, including but not limited to sentinel events, Root Cause Analysis, Failure Modes and Effect Analysis (FMEA) processes, and patient satisfaction.
In partnership with the compliance department, performs organizational risk assessments, identifies opportunities for improvement, and implements plan.
Instills principles of qualities at all levels, helping everyone in the organization feel driven to achieve excellence.
Leads continuous improvement programs throughout the organization and helps develop a culture of continuous improvement and excellence.
Maintains current competency and expertise in quality and patient safety.
Monitors quality dashboards and publicly reported performance metrics for opportunities for improvement.
Organizes and facilitates the quality committees and key strategic quality improvement/patient safety initiatives.
Oversees Baldrige readiness, quality measurement, ISO 9001, and Det Norske Veritas (DNV) accreditation, holding staff and departments accountable for achieving performance goals.
Oversees education and communication of quality improvement initiatives, quality and patient safety In partnership with education, develops and teaches patient safety, and performance improvement tools programs.
Oversees the direct operation of the quality improvement/patient safety department and its staff and budget.
Promotes a culture of safety, high-reliability, patient and staff engagement, and performance excellence.
Provides a planned, efficient, system-wide approach to identifying, designing, measuring, prioritizing, and monitoring all quality improvement and patient safety initiatives.
Provides resources and expertise for workflow analysis and process re-engineering.
Responsible for understanding and educating staff on publicly reported measures.
Supports and assists in the development of a Peer Review Process as assigned by senior medical leadership.
Supports and mentors employees of the department and other staff, students, and trainees with interest in quality and patient safety.
Supports, promotes, and encourages a culture of safety, high reliability, and patient and staff engagements throughout the organization.
Takes a clinical leadership role in evaluating care delivery and developing the infrastructure for improvement.
Works closely with both clinical and non-clinical teams for improvement on key performance indicators, designs processes for new initiatives, services and other targets.
Other duties as assigned.
Qualifications
Required
A minimum of five years of relevant acute care experience in quality, patient safety, regulatory and accreditation, or performance improvement
Bachelor’s degree in nursing with a current Minnesota RN license
Five years of experience in progressively more responsible healthcare leadership positions
Knowledgeable and experienced in Lean, Six Sigma, PDSA, process re-engineering, or other performance improvement methods with record of successful improvement projects
Strong record of leadership, project management, and collaboration
Demonstrated analytic and computer skills including use of statistical process control charts with strong writing, problem-solving, and communication skills
Experience in directing/leading a performance improvement and patient safety program in both a hospital and ambulatory care setting
Ability to motivate, lead, organize, communicate, and comprehend complex clinical data
Highly developed interpersonal skills and ability to build interpersonal relationships towards creative problem solving in a collaborative environment
Preferred
Graduated from an accredited college or university with a Master's degree in Healthcare Administration, nursing, or other health related field
Experience in managing and working towards achieving quality related awards (i.e. Magnet, Baldridge, PCMH etc.).
Certified Professional in Healthcare Quality (CPHQ) or Health Care Quality Management (HCQM)
For more information, please contact Katherine Shubnell at 313.806.4005 or kshubnell@daudlinsearch.com
About Olmsted Medical Center
Olmsted Medical Center (OMC), a 501(c)3 non-profit organization, has been southeastern Minnesota’s hometown healthcare provider since 1949. OMC’s 168 clinicians join over 1,300 other healthcare professionals serving at over 20 locations, including two multi-specialty clinics, a Level IV trauma hospital with 24-hour emergency room, a Skyway Clinic in downtown Rochester, and 11 community branch clinics. OMC also offers walk-in FastCare and Acute Care clinics. OMC has more than 35 specialties and is best known for its convenient, quality personal care. Each year, the Olmsted Medical Center team sees over 334,000 patients, performs nearly 4,100 major surgical operations, cares for over 22,000 patients in our Emergency Care department, and delivers nearly 1,000 babies.
