Columbia Memorial Hospital Director of Quality

Department Overview:

This position, although employed by OHSU, will be expected to be on-site at Columbia Memorial Hospital. The Columbia Memorial Hospital Director of Clinical Quality is responsible for providing leadership oversight and accountability for Quality, Peer Review, and Employee Health across the organization's continuum of care. They will apply expertise to drive organizational performance improvement and serve as an adviser and contributor to the development and execution of system strategy, high reliability, patient and caregiver safety, accreditation, and policies. As part of their expertise, they will oversee the process of responding to patient complaints and grievances, including service recovery. This individual will collaborate closely with the Director of Quality and Safety at OHSU to align organizational and departmental quality metrics and initiatives between the two organizations. The CMH Director of Clinical Quality will report to the CMH Chief Medical Officer (CMO) with a dotted line relationship to the OHSU Director of Quality and Safety.

Function/Duties of Position:

Administrative Functions:

• Models and supports CMH’s Mission, Vision, and Values, including compassion, accountability, respect, empowerment, and safety.
• Knowledgeable and skilled in roles/responsibilities and functions of operation of department(s).
• Participates in hospital/professional staff committee meetings as required.
• Demonstrates effective leadership skills in delegation, organization, and coordination of the department's operation.
• Maintains contact with and reports promptly to the senior leadership representative.
• Completes monthly administrative reports on a timely basis.
• Maintains current licensure/certifications.
• Holds daily safety huddles in addition to a minimum of monthly staff meetings and maintains records of those staff meetings.
• Acts as liaison between the Professional Staff and Administration as appropriate.
• Maintains department reports and records and collects statistical data as needed for administrative and regulatory purposes.
• Ensures compliance with local, state, and federal regulations related to security, workplace safety, and environmental care.
• Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of the latest trends in fields of responsibility.
• Attends and participates in department manager meetings and other meetings as assigned.
• Maintains an excellent attendance record, notifying the senior leadership representative of any unscheduled absence or tardiness.
• Must be able to see a clear vision of the department and its operations.
• Must be able to see the Hospital as a whole and how actions affect other departments and customers.

Department Specific Responsibilities:

• Set CMH strategy for the Quality, Peer Review, Event Reporting, and Employee Health programs in conjunction with CMH Hospital and Professional Staff leadership.
• Develop and implement annual QAPI plan. Monitor for effective implementation and provide status reports as required.
• Measures and reports on quality, safety, and peer review requirements, quality analytics and the performance of initiatives’ implementation.
• Recommends and facilitates proactive organizational change based on identified OHSU system and CMH metrics to improve quality and patient safety in collaboration with OHSU Director of Quality and Safety and CMH leadership.
• Provides oversight over Root Cause Analyses to ensure a meaningful and sustainable action plan for adverse events.
• Oversees reporting process of safety events/caregiver concerns in the CMH reporting system.
• Collaborates with others to create and maintain reports for CMH stakeholders including, but not limited to, the Board of Trustees, Quality Oversight Committee, and Professional Staff committees.
• Provides education/training in quality management strategies, tools, and issues to managers, staff, professional staff, and the CMH Board of Trustees as needed and requested at least annually.
• Collaborates actively with professional staff leadership to plan and direct quality improvement and safety initiatives.
• Collaborate on and participate in CMH High Reliability Organization (HRO) activities, Accreditation programs, and Policy review and revision processes as assigned.
• Oversee and coordinate the submission of all required Department of Quality-related documents and public reports to accrediting and oversight organizations including, but not limited to, ACHC, CMS, OHA.

Customer Service:

• Understands internal and external customer requirements, identifies performance gaps and priorities, and develops strategies to ensure integration and organizational performance.
• Contributes to the Performance Improvement Process and supports staff involvement.
• Identifies patient/customer needs and develops quality programs to meet those needs.
• Frequently solicits and utilizes staff input to improve service, productivity, and accuracy.
• Performs other related duties as assigned.
• Collaborates on the patient experience survey process, including monitoring of responses and caregiver orientation on the platforms used. Supports the development of strategies to improve satisfaction.
• Oversees process of responding to patient complaints and grievances including service recovery.

Policy/Procedure:

• Provides oversight over the development of policies and procedures that support quality including the process of policy review and revision.
• Establishes and maintains department policies and procedures, objectives, and quality assurance programs in conjunction with OHSU and CMH organizational leaders.

Financial:

• Accountable for the CMH department operating within budget.
• Manages applicable contracts.
• Assess present and future needs, trends, and problems within the areas of responsibility.

Required Qualifications:

Education:

• Bachelor’s degree is required in healthcare-related field.
• CPHQ (Certified Professional in Healthcare Quality) certification. If not currently certified, must complete certification within the 1st year of employment.

Experience:

• 5 years of progressive leadership/quality management experience in an acute care hospital setting.

Job Related Knowledge, Skills and Abilities (Competencies):

• Able to demonstrate leadership and managerial ability with excellent oral and written communication skills.
• Have strong interpersonal skills and a demonstrated ability to work collaboratively.
• Have proven success in a related role, including hospital quality reporting and compliance with regulatory requirements.
• Have knowledge of accepted medical and clinical practice/procedures, patient safety strategies, accreditation requirements, and Employee Health strategies.
• Have demonstrated knowledge of performance improvement and statistical principles.
• Proficient in Microsoft Office and have a working knowledge of word processing and databases.

Preferred Qualifications:

• Master’s degree in nursing or other relevant healthcare field preferred.
• RN currently licensed with the State of Oregon Board of Nursing.
• 5 years of progressive leadership/quality management experience in an acute care hospital setting.

Additional Details:

The CMH Director of Clinical Quality will work 5 days a week onsite at Columbia Memorial Hospital in Astoria, OR. This is a fully in-person position.

All are welcome: Oregon Health & Science University values a diverse and culturally competent workforce. We are proud of our commitment to being an equal opportunity, affirmative action organization that does not discriminate against applicants on the basis of any protected class status, including disability status and protected veteran status. Individuals with diverse backgrounds and those who promote diversity and a culture of inclusion are encouraged to apply. To request reasonable accommodation contact the Affirmative Action and Equal Opportunity Department at 503-494-5148 or