In collaboration with other clinical leaders in the Regional Group, is responsible for ensuring that patient care is delivered within the framework of evidence-based practice throughout the health system continuum and for understanding existing and emerging requirements in healthcare quality, safety, service/experience, and operational improvements.
Responsible for researching and recommending the annual quality management objectives. Facilitates medical staff and other committee meetings that are conducting quality and peer review activities. Directs the daily activities of the Quality Management Department and its staff responsible for the region. The Quality Management Department consists of quality, infection prevention, regulatory, risk management, and patient safety. Designs the measurement techniques, audits, and data reports that evaluate the attainment of the quality objectives of the hospital, region, and system. Educates the hospital and medical staff on matters related to quality. The Regional Director of Quality Management oversees and coordinates the process of regulatory accreditation including preparing and monitoring the hospital staff for a constant state of readiness, compliance with standards, and promoting a culture of safety. In collaboration with CHRISTUS Health & CHRISTUS Hospital Senior leaders, facility leaders, physicians, and the Board of Directors, he/she collaborates with other leaders to develop the strategic direction for the overall delivery of high-quality patient care across the continuum of health care service specifically related to improving organizational performance. This Job is responsible for the design, implementation, tracking, and reporting of clinical quality of care and patient safety efforts in alignment with the corporate strategies for performance improvement.
Responsibilities:
Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
Regional leaders are responsible for effectively collaborating with local leadership teams to meet accountability measures including, but not limited to, labor productivity standards, quality metrics, associate engagement, and retention efforts, as well as service level agreements to the consumer.
Provides expertise in quality management for inpatient and hospital outpatient department delivery settings.
Works collaboratively with the Chief Medical Officer and Chief Nursing Officer on quality management initiatives.
Provides leadership and expertise for integrating CHRISTUS multidisciplinary activities into quality management processes that include the utilization of national benchmarks, internal goals, and local targets.
Works collaboratively in a team environment to promote patient quality of care and safety.
Oversees continual compliance readiness with regional leadership in providing Joint Commission and other accrediting or licensing body reviews and education.
Provides oversight for the facilitation of the Quality Council, Infection Control Council, and the Patient Safety Council.
Provides quality management reports to the Quality Management Committee, a sub-committee of the Regional Board of Directors.
Language Ability: Excellent communication skills. Ability to write reports, business correspondence, and policy and procedure manuals. Ability to effectively present information to Associates, Executive Leadership, Committees, and the Board.
Reasoning Ability: Ability to use critical thinking.
Computer Skills: Must be proficient in the use of Microsoft Excel, Word, PowerPoint, and the Internet.
Quality Leadership and Integration- Advance the organization's commitment to health care quality through collaboration, learning opportunities and communication. Lead the integration of quality into the fabric of the organization through a coordinated infrastructure to achieve organizational objectives. Domain Level: Advanced.
Performance and Process Improvement- Use performance and process improvement (PPI), project management and change management methods to support operational and clinical quality initiatives, improved performance and achieve organizational goals. Domain Level: Advanced.
Population Health and Care Transitions- Evaluates and improve health care processes and care transitions to advance the efficient, effective, and safe care of defined populations. Domain Level: Proficient.
Health Data and Analytics- Leverage the organizations analytic environment to help guide data-driven decision-making and inform quality improvement initiatives. Domain Level: Advanced.
Regulatory and Accreditation- Direct organization wide processes for evaluating, monitoring, and improving compliance with internal and external requirements. Lead the organization's processes to prepare for, participate in, and follow up on regulatory, accreditation and certification surveys and activities. Domain Level: Advanced.
Patients Safety- Cultivate a safe healthcare environment by promoting safe practices, nurturing a just culture, and improving processes that detect, mitigate, or prevent harm. Domain Level: Advanced.
Quality Review and Accountability- Direct activities that support compliance with organization-wide voluntary, mandatory, and contractual requirements for data acquisition, analysis, reporting, and improvement. Domain Level: Advanced.
Professional Engagement- Engage in the healthcare quality profession with a commitment to practicing ethically, enhancing one's competence, and advancing the field. Domain Level: Proficient.
Job Requirements:
Education/Skills
Bachelor?s degree in Health Care Administration, Nursing, or a relevant clinical discipline with evidence of additional training in Quality required.
Master?s degree in Nursing or other healthcare related profession is strongly preferred.
Experience
5 years of experience in a strategic quality position in a complex healthcare environment required.
Licenses, Registrations, or Certifications
Current Certified Professional in Health Care Quality (CPHQ) required or actively seeking the certification within 1 year of hire date.
Current Texas license in a relevant clinical discipline is required.
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.
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NAHQ wants to partner with you and your organization as you explore how to elevate the profession and advance the discipline of healthcare Quality & Safety.
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For customer service issues, contact us at info@nahq.org or call us at (847) 375-4720. The team is available Monday-Friday from 8 AM-4:30 PM CT.
Important Information for CPHQ Recertification
The recertification process has been streamlined. Unlike previous years, you don’t need to list out your CE activities at the time of completing your application. Instead, you will be asked to attest to having met the requirements, further aligning with the honor-based system of recertification. In the event that your application is randomly selected for audit, you may be required to list your CE activities and submit supporting documentation.
While you may participate in NAHQ learning opportunities (Learning Labs, JHQ articles, etc.), you can only claim CE credit once for each activity. Therefore, if you’ve previously earned CE from a NAHQ learning opportunity, you can’t claim it again, nor will you see the repeat CE appear in your “My Learning� tab. This includes activities used in previous recertification cycles.
Remember, if you’re recertifying during the grace period (1/1/24-1/31/24), you already had to earn your CE hours by Dec 31, 2023.
You still have time! Register today for a multi-day virtual event that addresses the most urgent and important issues facing healthcare today that offers a full schedule of educational sessions organized around NAHQ’s twice-validated healthcare quality competency framework.
We are excited to announce the release of the book “UNSTOPPABLE: Inspiring Stories of Perseverance, Triumph and Joy from Trailblazing Women in Healthcare“.
Be inspired by nine leading healthcare trailblazers, including our own CEO Stephanie Mercado, who empower us all with their vision and passions.
You’ll notice we’ve simplified the application process to recertify. You will not have to list your CE activities at the time of applying*. Simply attest that you met the requirements to complete the application.
*In the event of an audit, CPHQs may need to list activities and upload documentation in their NAHQ account.
Quality Education Resources
Join this informative session, “Quality Education Resources� Thursday, June 22 from 11-11:30 a.m. CT. You will learn about the range of NAHQ quality education resources available to you and hear directly from universities about the benefits they realized from implementing NAHQ’s content within their courses.
Maintain a Pulse on the Latest Quality & Safety Benchmarking Data
Learn more about NAHQ’s enhanced Quality and Safety Benchmarking Program, which provides timely insights to help U.S. hospitals and health systems create data-driven business cases for their quality and safety resourcing.
Understand the Variability Among Your Quality Team Through Workforce Accelerator
Join us Tuesday, May 2, at 11 a.m. CT, to learn more about the different options available to engage with NAHQ’s enterprise-wide solution, Workforce Accelerator®. Options range in size and scope and are designed to meet the various budgetary and timing needs of health systems as they embark on their quality journeys. Register today!
Healthcare Quality and Safety Workforce Report: New Imperatives for Quality and Safety Mean New Imperatives for Workforce Development
The National Association for Healthcare Quality® (NAHQ) has conducted groundbreaking research on the advancement of the quality and safety agenda and has published the results in a new workforce report. NAHQ’s Healthcare Quality and Safety Report answers the question: “Is today’s healthcare workforce doing the work that will advance critical priorities of quality, safety, equity, value, and system sustainability?� The answer is no.
Updated Maintenance Dates: Sunday, February 5, 2023
Maintenance is planned for Sunday, February 5, from 11 p.m.-4 p.m. CT. During this time, you will not have access to the “My Learning” section of your NAHQ account. We apologize for any inconvenience this may cause and thank you for your patience.
NAHQ’s Organizational Membership Subscription will serve as a one-stop shop for healthcare quality and safety training and education. Attend the February 2, at 11 a.m. CT, info session to further understand the new offering that will continue NAHQ’s focus of “Quality in Action.�
NAHQ has published an updated version of the CPHQ exam content outline.
The new exam content will take effect on March 15, 2023. Candidates planning to take the exam before March 15, 2023, can access the current CPHQ exam content outline and related resources on our website.
Missed NAHQ Next? Don’t worry, you can purchase NAHQ Next on-demand and receive access to all content for 60 days from purchase. Benefit from actionable content that addresses issues head-on and features “how-tos” and results. Buy now and have the opportunity to receive 40+ CEs.
Healthcare Quality and Safety Workforce Report: New Imperatives for Quality and Safety Mean New Imperatives for Workforce Development
Member Briefing Workshop and Healthcare Quality Week Webinar
October 7, at 12 p.m. CT
NAHQ will host an exclusive member briefing workshop where NAHQ CEO Stephanie Mercado and NAHQ President-Elect Nidia Williams will review the workforce report in-depth and prepare you to discuss it with your team and leadership during Healthcare Quality Week.
October 17, at 12 p.m. CT
To kick off Healthcare Quality Week, (HQW) NAHQ will host a complimentary webinar with NAHQ leaders to discuss the report, its impact and how you can leverage the report to your advantage.
You still have time! Register today for a multi-day virtual event that addresses the most urgent and important issues facing healthcare today that offers a full schedule of educational sessions organized around NAHQ's twice-validated healthcare quality competency framework.