In association with senior leadership at Sinai-Grace Hospital, and in conjunction with the DMC Chief Quality and Medical Safety Officer, provides leadership for the development and implementation of the Sinai-Grace Hospital Quality Improvement, Environment of Care and Infection Control programs.

Develops and implements site and system policy and procedure modifications including program development and standards for program services. Develops site priorities for improvement and guides the site in the implementation and support of a clinical improvement and measurement methodology which will assist in achieving high clinical outcomes and quality patient satisfaction. Maintains a collaborative relationship with the medical staff to assist with the development of clinical services, the provision of quality patient care and the medical staff peer review process. Works collaboratively with the DMC Chief Quality and Safety Officer and other sites to identify and address medical safety issues and coordinate efforts to reduce errors.

Coordinates site efforts to meet accreditation and regulatory requirements on a continuous basis (i.e., JCAHO, MPRO, QMS/ISO, etc.). Provides leadership in promoting the continuous improvement methodology, tools, and incident reporting/risk reduction. Serves in a leadership role on the site LPICC and other committees. Oversees the development of policies for the area of responsibility. Approves policies and/or seeks other system, regional, clinical service approval as appropriate. Ensures the development of function procedures/protocols and secures system approval as necessary. Oversees the development of functional processes. Creates and seeks approval of organizational structures. Develops short to long-range goals and measures for areas of responsibility and oversees the assessment of goal attainment. Develops, seeks approval of, monitors and ensures compliance with budget. Monitors activities for and ensures compliance with laws, government regulations, JCAHO requirements, and DMC policies. As directed, implements external and internal audit recommendations. Ensures hospital departments achieve objectives for diversity of their suppliers.

Qualifications:

1. Bachelor's degree in Health Care Administration, Operations Analysis, clinical or other related fields, or the equivalent combination of education and/or experience. Masters degree preferred.

2. Three years of professional-level experience in continuous improvement in a health care environment, including at least one year of experience in the utilization of continuous improvement statistical methods and tools.

3. Three to five years of leadership experience in an acute care facility with at least one year of involvement with senior management and physician leaders.

4. Experience in the use of personal computers as well as knowledge of statistical or spreadsheet software tools preferred.