Eastern Region Director, Quality & Safety
Company: Trinity Health
Posted on: January 23, 2023
Employment Type:Full timeShift:Day ShiftDescription:The Eastern
Region Director of Quality & Safety is a member of the MercyOne
Eastern Iowa Regional Executive Team. The purpose of the role is to
lead quality and safety programming that consistently cultivate
high standards and excellent outcomes in all dimensions of
performance. In collaboration with the Regional Executive Team,
establishes quality and safety structures that culminate in high
reliability.The Eastern Region Director of Quality & Safety
provides leadership in the development and implementation of
performance excellence strategies related to clinical indicators,
outcome measures, process improvement methodologies and services
that ensure high quality, safe care. This role has accountability
for the following departments/functions: Quality, Risk Management,
Infection Prevention, Accreditation, performance excellence (LEAN),
and culture of safety (TogetherSafe). In addition, the Director of
Quality and Safety provides support and oversight for the medical
staff services department.ESSENTIAL FUNCTIONS:
- Knows, understands, incorporates and demonstrates the MercyOne
(Trinity Health) Mission, Vision, Core Values, Actions and Promise
in behaviors, practices, and decisions.
- Provides leadership, strategic direction, guidance and
oversight with respect to quality improvement and safety, infection
prevention and risk management initiatives, performance excellence
(LEAN), culture of safety (TogetherSafe) and accreditation
readiness across the MercyOne Eastern Iowa region. Assesses
effectiveness of all areas of responsibility and adjusts to ensure
consistent operational effectiveness.
- Fosters and cultivates a high reliability mindfulness focused
on creating exceptionally safe and consistently high-quality care.
Demonstrates a relentless pursuit of a culture of safety where zero
harm is the highest priority.
- Develops an overall performance improvement plan consistent
with the strategic plan, and in conjunction with the Regional
Executive Team, Senior Leadership Team of each market hospital, and
quality improvement committees (QICs), the Medical Executive
Committees, and the Board of Trustees/Directors.
- Works strategically with the medical and nursing staffs and
system leaders to develop quality and safety strategic plans and
infection prevention plans.
- Provides direct supervision of the staff and assists in their
development and competency.
- Provides leadership for regional quality/safety/infection
prevention committees, including Board quality committees and
provides direction for the medical center's QICs.
- On an on-going basis, identifies problem areas in need of
focused attention - plans and oversees implementation of actions to
drive improved outcomes.
- Achieves the best outcomes aligned to CMS and other pay for
performance programs, including those that are aligned to
- Provides leadership and ensures regulatory compliance,
including continuous Joint Commission readiness, CMS (including pay
for performance programs, star quality program, etc.) and the Iowa
Department of Inspections and Appeals compliance as pertains to
quality and patient safety.
- Provides leadership for continued improvement with regards to
outside rating organizations, including: CMS, Leapfrog, US New and
World Report, Health-grades, etc.
- Collaborates with the VP of Patient Care and nursing leaders in
meeting/exceeding Magnet standards of excellence and achieving
- Develops performance excellence systems that integrate LEAN and
other methodologies as appropriate to create a premier data-driven
quality improvement programming across the region. In collaboration
with clinical leadership, participates in the development,
monitoring, reporting, and improvement of quality/patient
safety/infection prevention activities related to their respective
- Provides appropriate oversight, support, and/or consultative
services (project design, selection of data required, development
of documentation tools, etc.) to quality improvement teams.
- Develops and implements a plan to improve the organization's
Culture of Safety - including the concept of a Just Culture and
- In coordination with Risk Management, recommends and supports
opportunities for improvement on all Root Cause Analyses (RCAs) to
ensure completeness, thoroughness, creditableness and
- Analyzes, aggregates, tracks and trends occurrences/sentinel
events/RCAs and identifies outcome reports to include corporate and
facility specific trends and patterns.
- Oversees clinical data gathering/analytics.
Develops/facilitates accuracy of scorecards/dashboards that enable
clear reports for internal and external customers.
- Collaborates with the senior leadership team in the development
and implementation of operating and capital budgets.
- Promotes an environment of shared leadership and
- Maintains a working knowledge of applicable Federal, State, and
local laws and regulations, Trinity Health's Organizational
Integrity Program, Standards of Conduct, as well as other policies
and procedures in order to ensure adherence in a manner that
reflects honest, ethical, and professional behavior.
- Supports organizational evidence-based practice, innovation and
research and facilitates engagement with the MercyOne IRB.
- Oversees and guides the clinical contracting process,
consistent with legal and regulatory requirements.
- Contributes to the process for evaluating medical staff
performance, including the focused and ongoing professional
performance review process.
- Provides administrative oversight and support of the medical
staff services department and the Medical Executive Committee.
- Maintain awareness of and respond to issues in areas including
the following:o Ethnic, cultural and diversity changes in the
populationo Political and social influenceso Financial and economic
issueso The aging of societyo Ethical issues related to
- Perform other duties consistent with purpose of job as
directed.SKILLS AND ABILITIES REQUIRED:
- A thorough understanding of the health care environment and all
applicable laws and regulations.
- In depth knowledge of high reliability organizations,
performance excellence, change leadership, shared governance,
matrix reporting, continuous improvement, risk management and
financial and productivity management.
- The ability to synthesize and interpret large amounts of
clinical, quality, and financial data.
- Proven time management skills with the ability to prioritize
and organize work/projects in a fast-paced working environment so
that all tasks are completed on time and accurately.
- Keeps current in area of expertise and assure that standards
and practices reflect best practice within area of expertise.
- Maintains a professional, collaborative work environment so as
to foster a positive public image for MercyOne.
- Possesses a personal presence that is characterized by a sense
of honesty, integrity, and caring with the ability to inspire and
motivate others to promote the philosophy, mission, vision, goals,
and values of MercyOne and Trinity Health.
- Provides a high level of customer responsiveness and serves as
a role model to encourage a commitment to customer service. A
strong service orientation is required.
- Excellent written and verbal communication skills with the
ability to relate to people across all levels & diverse
backgrounds; ability to handle interactions with discretion, tact &
- Strong relationship builder, consultant and demonstrate the
ability to deal successfully with inherent ambiguities and
complexities of a multi-site organization.
- Demonstrates leadership and management abilities. Highly
skilled in management technique, primarily in the areas of
consensus and team building, colleague engagement, delegation,
conflict management, etc.
- Flexible and demonstrates a great tolerance for change with
ability to manage self and others through change.
- High aptitude for learning quickly, acting maturely and
- Ability to think creatively and analytically.
- Ability to demonstrate initiative.
- High degree of professionalism.
- Ability to handle confidential information in a sensitive
- Demonstrates leadership skills and ability to implement
processes and procedures.EDUCATION, LICENSURE, CERTIFICATION, AND
- Education:o Masters Degree in Nursing. Doctoral education
preferred.o Iowa licensure as a Registered Nurse.
- Experience:A. Requires a minimum of five (5) years progressive
leadership experience, preferably at the director level.B. National
certification in risk management and/or quality/safety required or
must acquire within 2 years of hire. LEAN Six Sigma certification
- Special Skills, Competencies, and Aptitudes:A. Member of a
professional nursing organization.B. Demonstrated expertise in the
use of performance improvement methodology/tools.C. Must be able to
use computers for documentation and other relevant activities.
Demonstrates specific knowledge related to software programs such
as VOICE (or other incident reporting system) and other appropriate
software programs. Experience with computer applications such as
Microsoft Office Suite (Word, Excel, PowerPoint, Outlook),
HealthStream, Intranet, and use of reporting tools. Helpful to have
experience with PowerChart or similar tool.Our Commitment to
Diversity and InclusionTrinity Health is a family of 115,000
colleagues and nearly 26,000 physicians and clinicians across 25
states. Because we serve diverse populations, our colleagues are
trained to recognize the cultural beliefs, values, traditions,
language preferences, and health practices of the communities that
we serve and to apply that knowledge to produce positive health
outcomes. We also recognize that each of us has a different way of
thinking and perceiving our world and that these differences often
lead to innovative solutions.Our dedication to diversity includes a
unified workforce (through training and education, recruitment,
retention, and development), commitment and accountability,
communication, community partnerships, and supplier diversity.Our
Commitment to Diversity and InclusionTrinity Health is a family of
115,000 colleagues and nearly 26,000 physicians and clinicians
across 25 states. Because we serve diverse populations, our
colleagues are trained to recognize the cultural beliefs, values,
traditions, language preferences, and health practices of the
communities that we serve and to apply that knowledge to produce
positive health outcomes. We also recognize that each of us has a
different way of thinking and perceiving our world and that these
differences often lead to innovative solutions.Our dedication to
diversity includes a unified workforce (through training and
education, recruitment, retention, and development), commitment and
accountability, communication, community partnerships, and supplier
diversity.EOE including disability/veteran
Keywords: Trinity Health, Dubuque , Eastern Region Director, Quality & Safety, Executive , Dubuque, Iowa
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