Director Quality Acute - South

Join Community 

Community Health Network was created by our neighbors, for our neighbors. Over 60 years later, “community” is still the heart of our organization. It means providing our neighbors with the best care possible, backed by state-of-the-art technology. It means getting involved in the communities we serve through volunteer opportunities and benefits initiatives. It means ensuring our dedicated caregivers can learn and grow to stay at the top of their fields and to better serve our patients. And above all, it means exceptional care, simply delivered — and we couldn’t do it without you. 

Make a Difference 

Reports to hospital leadership, Administrator/Chief Nurse Executive/VPO, with matrixed structure /dotted lines to the Network VP Quality & Risk, Network CMO, Executive Physicians, Regional/local President, and other leaders. Responsible for coordination and successful execution of all Quality activities which include leading performance improvement work, leading accreditation efforts via Joint Commission and regulatory compliance survey processes, patient safety and risk management, and infection prevention programs. Performs other responsibilities as required for the effective, safe, or efficient functioning/operation of the hospital, department and organization. Collaborates and participates across the network as needed 

Exceptional Skills and Qualifications 

Applicants for this position should be able to collaborate with others in a team setting, have excellent communication skills, and a positive attitude toward problem-solving. 
 

• 4 year / Bachelor's Degree BSN and/or Masters prepared or level of knowledge equivalent to that ordinarily acquired through completion of Master's Degree in Nursing, Social Work, Infectious Disease, Public Health and/or Pharmacy (Required)  
• Master's Degree (Preferred) 
• Certifications/Licensures: (as dictated by healthcare discipline) Registered Nurse (RN) with a valid license to practice in the state of Indiana as listed in the Nurse Licensure Compact (NLC) ), LCSW, Pharmacy and/or other discipline. (Required) 
• Certifications/Licensures: Certified Professional Healthcare in Quality (CPHQ) to be obtained within 3 years from hire (Required)  
• 7+ years: Clinical experience with a minimum of three years of progressive quality management administrative experience in a healthcare setting required. Nurse, Pharmacist, Infection Prevention, Lab, Social Work, Patient Safety experience is also acceptable. Experience with accreditation and regulatory compliance survey processes preferred. (Required)

• Quality Accountabilities: Responsible for and manages the assigned Quality, Infection Prevention, and Patient Safety and Risk Management Department activities through the development and implementation of an effective organizational structure, staff supervision, and planning. Leads and coordinates performance improvement processes and provides consultative services to assist in achieving regulatory, accreditation, and organizational compliance in quality and performance improvement activities so that regulatory standards are met and accreditation efforts are coordinated. Takes an active leadership role in accreditation activities to educate and assist with regulatory readiness. Responsible for organizing and submitting action plans and collaborating with the network VP of Quality and the NCOC governance requirements, developing the chapter leaders, and utilizing AMP software tool to analyze performance, prioritize improvements, assess organizational risk and submit reports timely. Establishes specific quality related goals to measure the organization's processes and outcomes. Provides leadership, back-up and local support to the network infection prevention functions and Patient Safety and Risk Management functions. Develops and oversees the implementation of an effective Organization-wide Quality Management program with the Medical Staff and hospital leadership so that: Clinical and Non-clinical processes, outcomes, and satisfaction are regularly measured and benchmarked, aggregated, analyzed and reported to assigned groups. Conclusions may be drawn, actions taken, follow-up performed, and improvements made and maintained. Reports of the above activities are made to work groups, committees, clinical core groups, Medical Staff Sections, Medical Staff Departments, the Medical Staff Executive Committee, and the Network Board Quality of Care Committee (QoCC) as requested. Promotes and cultivates proactive, rather than reactive, quality efforts by managing variability, ensuring strong process/procedure design and effective process management. Supports the Network focus on standardization to reduce variation and leads teams that identify root causes of problems rather than focusing on individuals. Acts as a change agent to identify opportunities to improve, resolve problems and evaluate the effectiveness of change and administer programs that focus on improved outcomes of patient care. Coordinates the use of multiple clinical decision support databases available to support value analysis, outcome analysis and change management. Supports the organization’s safety program through an exchange of patient safety, quality and infection prevention information, input into safety education and orientation, as well as providing assistance in investigating situations which pose a possible liability to the organization. Maintains confidentiality of sensitive patient and provider specific information