Director of Quality Improvement, Hospital Based Services

Director of Quality Improvement, Hospital Based Services Job Number: 00135504

Job Posting : Oct 11, 2024, 3:01:15 PM Closing Date : Ongoing
Full-time Shift Start Time : 8:00 A.M. Shift End Time : 4:30 P.M.

Posting Salary : MIN $160k - MAX $179,800

Organization : Health and Hospital Systems

Applicants may apply for this position by submitting a resume/ CV to the following email address:

When submitting a resume/CV by email, you must include the job title and posting number in the subject line of your email.

This position is exempt from Career Service under the CCH Personnel Rules.

Job Summary

The Cook County Health & Hospitals System (CCHHS) is one of the largest public hospital systems in the nation. The System cares for over 25,000 inpatients annually and has almost 1 million clinic visits per year. The John H. Stroger, Jr. Hospital of Cook County has a Level 1 Trauma Center, a busy Emergency Department serving 140,000 patients per year, a full service OR and Maternal Child Services. The System is committed to excellence in the quality of care provided to its patients and seeks to demonstrate this quality by fill accreditation from Joint Commission.

The Director of Quality Improvement, Hospital Based Services is a health care professional with experience in directing quality, safety and performance improvement efforts in the hospital setting which may include community-based clinics. Provides organizational direction and oversight of quality metric reporting. Provides oversight of the Hospital patient safety program including the reporting and analysis of sentinel events and the development and implementation of a patient safety plan. Leads continual readiness efforts across the Hospital, including policy review, tracer activities, staff education and survey preparation and oversight. Responds to requests for information and collates and presents data as required by the Regulatory Agencies. Prepares and delivers reports to such agencies, as well as to Cook County governance including the CCH Board of Directors. Perform other duties assigned by the Chief Quality Officer.

General Administrative Responsibilities

Collective Bargaining

• Review applicable Collective Bargaining Agreements and consult with Labor Relations to generate management proposals.
• Participate in collective bargaining negotiations, caucus discussions and working meetings.

Discipline

• Document, recommend and effectuate discipline at all levels.
• Work closely with labor relations and/or labor counsel to effectuate and enforce applicable Collective Bargaining Agreements.
• Initiate, authorize and complete disciplinary action pursuant to CCH system rules, policies, procedures and provision of applicable collective bargaining agreements.

Supervision

• Direct and effectuate CCH management policies and practices.
• Access and proficiently navigate CCH records system to obtain and review information necessary to execute provisions of applicable collective bargaining agreements.

Management

• Contribute to the management of CCH staff and CCH’ systemic development and success.
• Discuss and develop CCH system policy and procedure.
• Consistently use independent judgment to identify operational staffing issues and needs and perform the following functions as necessary; hire, transfer, suspend, layoff, recall, promote, discharge, assign, direct or discipline employees pursuant to applicable Collective Bargaining Agreements.
• Work with Labor Relations to discern past practice when necessary.

Typical Duties

• Initiates and oversees the development of a comprehensive safety/quality/and Pl program inclusive of the analysis and trending of data including patient grievances and patient safety reports.
• Provides strategic oversight for quality committees with accountability for distribution of organizational communication.
• Prepares regular reports as needed for performance improvement and quality programs.
• Assesses entity compliance with accreditation standards and regulations related in collaboration with entity leadership and staff.
• In conjunction with the medical staff and system leadership, directs and coordinates quality/performance improvement initiatives.
• Fosters and maintains collaborative relationships within CCH and with external agencies, purchasers, and stakeholders related to quality/performance improvement initiatives.
• Regularly communicates Pl and quality activities to leadership and staff.
• Manages department budget and determines fiscal requirements and prepares budgetary recommendations.

Reporting Relationship

Reports to the Chief Quality Officer

Minimum Qualifications

• Master's or higher-level degree in a health-related discipline from an accredited college or university (Candidates who do not possess a license must provide official transcripts with evidence of coursework at the time of the interview).
• Five (5) years' clinical experience in a hospital setting.
• Five (5) years' experience in key roles in quality improvement at a system level.
• Previous experience with data analysis and interpretation.

Preferred Qualifications

• Two (2) years of leadership at a Director/Hospital Administrator level preferred.
• Ability to adapt and thrive in a complex organizational environment.
• Ability to function independently and under time constraints.
• Previous experience in clinic administration in a hospital care setting.
• Additional certification or coursework in quality improvement or patient safety.

Knowledge, Skills, Abilities and Other Characteristics

• Excellent leadership skills with operational experience in regulatory, safety, care management and related fields.
• Detailed knowledge of the regulatory environment including Joint Commission standards.
• Outstanding written and verbal communication skills.
• Must be detail oriented and have high standards of accuracy.
• Experience working with Electronic Medical Record Systems.
• Proficient in Microsoft Word and PowerPoint.

Physical and Environmental Demands

This position is functioning within a healthcare environment. The incumbent is responsible for adherence to all hospital and department specific safety requirements.

COOK COUNTY HEALTH IS AN EQUAL OPPORTUNITY EMPLOYER.