Director Performance Excellence & Quality

Under the direction of the HFHS Chief Quality Officer and matrixed to local Business Unit senior leadership (COO, CMO, CNO, and/or CEO as appropriate based on
Business Unit), the Director, Performance Excellence and Quality (PE/Quality) is responsible for planning, monitoring, and directing the effective implementation of key Performance Excellence (PE) and Quality/Safety (Q/S) strategies that support the objectives and results of the Business Unit.

Key responsibilities include overseeing daily activities of local performance excellence and clinical quality/safety staff including activities in the areas of risk management, infection prevention, regulatory readiness/accreditation, patient safety, process/quality improvement (PI/QI), and local strategic/action planning, including ensuring alignment of all activities to System goals and objectives. Collaborates with other local Business Unit leaders (including other Directors of PE/Quality) and relevant System-level leaders (including the Directors/Managers of Performance Improvement, Clinical Quality & Safety, Strategic Planning, and Performance Analytics) to stay apprised of new approaches, innovations, and integration opportunities. Interacts with or leads teams throughout the Business Unit and participates in System quality/safety/process improvement teams as appropriate.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

• Responsible for directing and supporting Business Unit excellence in performance of clinical Quality and Safety. This includes Core Measures, Pay for Performance, Quality Initiatives such as Blue Cross and Keystone projects, Patient and Employee Harm Avoidance, and Infection Control and Risk.
• Responsible for directing and supporting BU activities related to Regulatory accreditation and compliance, ensuring that the BU is fully compliant at all times,
  and responds in a timely manner to any regulatory requests as appropriate.
• Responsible for directing and supporting Performance Excellence and Quality personnel - in a matrix relationship to HFHS Performance Excellence and
  Quality/Safety Leadership - as they provide planning and performance excellence, services to the Business Unit and System (as regularly evaluated by Director and System leadership).
• In conjunction and coordination with the Corporate Strategic Planning and Performance Analytics departments, provides leadership and analytic support to the Business Unit strategic planning to develop and prioritize key strategies and action plans, including identifying and routinely reporting key measures of success.
• Is accountable for the ongoing development and improvement of the Business Unit's process and PI infrastructure. Leads processes to determine the appropriate application of Business Unit resources and methodologies to PI initiatives. Identifies opportunities for performance improvement across the Business Unit and, in conjunction with Business Unit administrative and physician leadership, proposes, plans, and executes improvement activities appropriate to the opportunity.
• Ensures appropriate data systems (including data warehouses, performance dashboards, and other systems including the HFHS Enterprise Data Warehouse)
  are properly utilized to respond to and meet the PI and quality and safety needs of the Business Unit and external constituencies, in conjunction with appropriate Business Unit and Performance Analytics leadership. Serves as the Business Unit liaison to HFHS Performance Analytics leaders/staff.
• Leads the Business Unit's continuing investigations regarding best practices in healthcare operations and healthcare performance improvement. Designs and
  oversees processes for evaluating potential opportunities, and develops appropriate opportunities into realized and quantified improvement.
• Working with appropriate System and Business Unit leadership, ensures Business Unit representation and participation in appropriate external collaboratives, think tanks, benchmarking groups, and other initiatives at local and national levels. Assumes leadership roles as appropriate. In partnership with System external reporting, value-based purchasing and P4P Leaders, ensures Business Unit key activities and staff are in place to optimize bonus/reimbursement payments for programs coordinated by third-party payer programs.
• Chairs and staffs Business Unit committees and meetings as needed. Participates as a member of the Business Unit Senior Leadership Team. Supports medical staff and quality committees (including Quality Committees of the Board) at the Business Unit and the System level through information sharing, presentations, and execution of initiatives as identified.
• Budget oversight for Business Unit appropriately related cost centers. Is fiscally responsible.

ADDITIONAL DUTIES AND RESPONSIBILITIES:

• Interacts regularly with Business Unit and other Corporate/System Senior Leaders as clients and principal decision makers about Performance Excellence and Quality/Safety functions. Works collaboratively with Business Unit administrators, managers, and physicians on projects within their areas.
• Serves as a change agent within HFHS, supporting both the identification and application of new quality/safety and performance improvement concepts, and
  sharing of local improvements throughout the System.
• In partnership with Corporate leaders as appropriate, interviews job applicants for departmental vacancies, recommends pay increases, and recommends discipline and termination of assigned personnel as warranted. Develops, implements, and enforces procedural standards for project activities. Estimates personnel requirements, time, and costs of Performance Excellence and Quality projects and functions.
• Performs resources planning and scheduling of departmental personnel, including employed clinical quality staff, engineers, consultants, and student resources, to ensure customer requirements are met.
• Other duties as appropriate.
  

May perform the following Emergency Management key functions:

• Assumes primary responsibility/expertise for system coordination of all aspects of emergency management to ensure safety of patients and employees during
  disasters/emergency situations and ensure business continuity.
• Coordinates system planning for mitigation, preparedness, response and recovery activities to ensure organizational efficiency; consistent communication; and standardization of operating unit incident commands.
• Serves as a liaison; subject matter expert to the operating unit staff regarding applicable safety requirements set forth by regulatory bodies including, but not
  limited to CMS and TJC; and supports education/training initiatives in response planning.
• Develops and leads a formalized emergency management structure at the system level including a dedicated system emergency management steering committee.
• Analyzes, synthesizes data for report compilation and presentation to leaders, stakeholders, including annual review of ongoing readiness/preparedness activities.