Director of Quality Improvement, Hospital Based Services

Full-time Posting Date : Oct 11, 2024 Closing Date: Ongoing

Shift Start Time: 8:00 A.M. Shift End Time: 4:30 P.M.

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

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. An application or resume/CV must be filed for each position which interests you.

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 performance improvement 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.
• 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 performance improvement and quality activities to leadership.
• 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
• 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. This includes but is not limited to the following policies and procedures: complying with Personal Protective Equipment requirements, hand washing and sanitizing practices, complying with department specific engineering and work practice controls and any other work area safety precautions as specified by hospital wide policy and departmental procedures.

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of the personnel so classified.

For purposes of the American with Disabilities Act, "Typical Duties" are essential job functions.

To receive Veteran Preference, appropriate discharge papers must be attached to the online application or must be included with your emailed resume/CV. Please refer to Veteran Preference document requirements listed on the bottom of this posting.

BENEFITS PACKAGE

Medical, Dental, and Vision Coverage

Basic Term Life Insurance

Pension Plan and Deferred Compensation Program

Employee Assistance Program

Paid Holidays, Vacation, and Sick Time

You may also qualify for the Public Service Loan Forgiveness Program (PSLF)

VETERAN PREFERENCE

PLEASE READ

When applying for employment with Cook County Health, preference is given to honorably discharged Veterans who have served in the Armed Forces of the United States for not less than 6 months of continuous service.

To take advantage of this preference a Veteran must:

• Meet the minimum qualifications for the position.
• Identify self as a Veteran on the employment application by answering yes to the question, "Are you a Military Veteran?"
• Attach a copy of their DD 214, DD 215 or NGB 22 (Notice of Separation at time of application filing. Please note: If you have multiple DD214s, 215s, or NGB 22S, please submit the one with the latest date. Coast Guard must submit a certified copy of the military separation from either the Department of Transportation (Before 9/11) or the Department of Homeland Security (After 9/11). Discharge papers must list and Honorable Discharge Status. Discharge papers not listing an Honorable Discharge Status are not acceptable.

OR

A copy of a valid State ID Card or Driver's License which identifies the holder of the ID as a Veteran, may also be attached to the application at time of filing.

If items are not attached, you will not be eligible for Veteran Preference.

VETERANS MUST PROVIDE ORIGINAL APPLICABLE DISCHARGE PAPERS OR APPLICABLE STATE ID CARD OR DRIVER'S LICENSE AT TIME OF INTERVIEW.

MUST MEET ALL REQUIRED QUALIFICATIONS AT TIME OF APPLICATION FILING.

Degrees awarded outside of the United States with the exception of those awarded in one of the United States' territories and Canada must be credentialed by an approved U.S. credential evaluation service belonging to the National Association of Credential Evaluation Services (NACES) or the Association of International Credential Evaluators (AICE). Original credentialing documents must be presented at time of interview.

*Please note all offers of Employment are contingent upon the following conditions: satisfactory professional employment references, healthcare and criminal background checks, appropriate licensure/certifications and the successful completion of a physical and pre-employment drug screen.

*CCH is strictly prohibited from conditioning, basing or knowingly prejudicing or affecting any term or aspect of County employment or hiring upon or because of any political reason or factor.

COOK COUNTY HEALTH IS AN EQUAL OPPORTUNITY EMPLOYER.