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Executive Director, Quality - St. Mary Medical Center

Company: St. Joseph Health
Location: Apple Valley
Posted on: November 15, 2021

Job Description:


The Executive Director Quality serves as a key ministry & regional executive and provides leadership and coordinates ministry and region-wide efforts directed at delivering cost effective, efficient, high quality, and safe care in Southern California for their service area. The position reports to the Regional Chief Quality Officer Southern California with dotted line reporting to ministry CMO. The Executive Director Quality will provide strategic clinical leadership and form a strong linkage between ministry clinical and operational leadership with direct oversight for quality, performance improvement, analytics, clinical risk, patient safety and regulatory compliance, peer review, infection prevention, care experience and patient grievances and complaints. In collaboration with the CQO and regional director Infection Prevention, provides direct ministry leadership and direction in the development and ongoing monitoring of the Providence St. Joseph Health Quality Strategic Plan (QSP).

The Executive Director of Quality will serve as the hands-on leader and clinical quality expert. The executive director quality will lead, facilitate and oversees activities designed to support sustainability of improvements to clinical quality, patient safety, clinical risk, infection prevention and care experience ,while using data effectively will also be expected to make meaningful contributions to quality and safety initiatives for the entire Region in collaboration with CQO. In addition, the executive will be a resource for current and emerging regulatory and compliance issues, patient safety program (HRO), root cause analysis, failure modes and effects analysis and future quality related initiatives based on regional and national networking and benchmarking of evidence based changes for all local, and service area organizations in the respective service area.


The Executive Director of Quality will:

  • Know, understand, incorporate and demonstrate the Providence St. Joseph Health Mission, Vision and Core Values in leadership behaviors, practices and decisions. Inspire physicians and others to reflect the mission, vision, and core values
  • Champion the continuous improvement of patient care to advance safety and quality outcomes, satisfaction, and efficiency initiatives across their service area and region.
  • Act as clinical dyad for their service area in southern California region
  • Develop and implement strategies to ensure cost effective, efficient care delivery for optimal quality, safety, experience outcomes
  • Work with local ministries leadership to develop a cost effective structure and develop required services and governance to redesign care and improve clinical outcomes
  • Create a compelling vision for clinical excellence and value that helps position PSJH as a leading provider in the region
  • Coordinate with local efforts in regulatory compliance
  • Assess and benchmark the current PSJH quality, safety, and clinical performance improvement processes, initiatives, resources, and outcomes against that vision
  • Ensure that the operational and clinical systems, resources, and processes are in place to meet PSJH Quality and Patient Safety Goals. In this effort, deploy clinical program improvement across the ministries in the service area and region
  • Identify and integrate best practices within and outside the system to create unified programs and knowledge-sharing tools that encourage front-line physician participation, engagement, and ownership in quality, safety, and clinical improvement initiatives and outcomes, as well as support the movement to value
  • Coordinate, integrate, and communicate clinical excellence initiatives in a manner which values the contributions of physicians and staff currently working in the quality, safety, and clinical improvement arena, while ensuring consistency of outcomes across the service area and region
  • Connect and integrate regional and facility-level resources in order to streamline systems and goals for effectively monitoring and reporting quality and safety in the ministries.
  • Ensure the existence of state-of-the-art scorecards and systems for tracking, evaluating, and communicating patterns in care delivery, patient safety, and health status
  • Monitor patient safety data for trends, recommend changes, as appropriate, and interface with risk managers to support patient safety and clinical loss prevention strategies, including the provision of expert consultation for patient safety/clinical loss prevention issues, as appropriate
  • Monitor care experience data for trends, recommend changes and support initiatives to improve care experience and reduction of grievances, supporting the cultural work related to caregiver experience
  • Co-Lead with the Regional CQO all Clinical Effectiveness initiatives with a goal to decrease cost per case and improve care efficiency
  • Participate in the on-going evolution of information systems for the purposes of tracking the effectiveness of quality and safety initiatives
  • Participate in PSJH Clinical Council meetings representing service area in the Region, in collaboration with the Regional CQO
  • Provide leadership and support for all clinical leaders in the acute care ministries in their service area, participate in MOR meetings to support their service area teams, as well as quality and improvement committees in their respective service area ministries
  • In collaboration with CQO, provide leadership and direction in identifying, developing and refining region-wide patient safety, quality improvement and reporting systems in a manner which ensures quality measures are included, properly analyzed and reported in internal and external PH&S reports and documents.


    Required experience/education for this position include:

    • An advanced degree, clinical degree is preferred (MD, RN, DO)
    • A minimum of seven years of experience clinical leadership and five years of senior management experience in a large health care organization with responsibility for leading clinical quality improvement functions is required, including experience as a clinical leader with responsibility for clinical quality and clinical leadership development and education; experience in a complex, multi-site health system; experience with The Joint Commission accreditation and DNV processes and standards
    • License to practice (nursing) in the State of California
    • Highly-effective interpersonal skills and a motivational approach to leadership which will 1) create excitement for the potential associated with achieving a higher standard in clinical excellence; 2) leverage existing leadership, resources, knowledge base, and best practices, and 3) serve as a thought leader in conceptualizing, communicating, and delivering on the myriad opportunities associated with clinical excellence
    • Demonstrated competence in:
      • Developing and managing a quality program in a hospital setting
      • Program development and design of clinical care systems with measurable results
      • Service and clinical quality improvement
      • Clinical Risk Patient Safety program implementation
      • Infection Control
      • Tools development to support process improvement and clinical excellence
      • Care experience encompassing caregiver/culture and patient experience
      • Developing trusting relationships with physician and ministry leaders
      • Utilization of data and reporting to drive urgency for change and improvement
      • Understanding and communicating culture of safety program concepts and tools
      • Facilitating process improvement and clinical excellence
      • Understanding the drivers for and improving patient experience
      • Executing on strategic objectives at multiple ministries
      • A strong commitment to the mission of Catholic healthcare
      • A leader who strategically, politically, instinctively, and operationally understands and can communicate concerns and issues within a highly-matrixed organization
      • A strategic systems thinker, accompanied by the orientation and presence to analyze and interpret complex data situations and relationships in a manner which envisions future delivery models/approaches. In addition, proven ability to partner with others in operationalizing highly conceptual and innovative health management strategies and achieving successful outcomes in the ministries in their service area.

        Preferred experience/education for this position include:

        • A master's degree in public health, business administration, medical management, or a related field.

          St. Mary Medical Center (SMMC) is an acute care hospital with 213 beds and over 1,750 employees making it one of the region's largest employers serving communities of the High Desert. The facility was constructed in 1956 and joined the St. Joseph Health System in 1992.

          This facility has the only Neonatal Care Unit in the High Desert Accredited by California Children Services and has been granted approval as a Special Hospital with the California Children's Services Community Neonatal Intensive Care Unit. St. Mary was accredited as a primary Stroke Receiving Center in 2018, the only stroke-receiving center in the High Desert.

          The Services and Clinical Specialties offered at this Hospital are Diabetes Education, Emergency Services, Heart and Vascular Services, Imaging Services, Rehabilitation Services, Respiratory Services, Robotic Surgery Services, Surgical Services, Women & Children's Services and Wound Care and Hyperbaric Medicine.

Keywords: St. Joseph Health, Apple Valley , Executive Director, Quality - St. Mary Medical Center, Healthcare , Apple Valley, California

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