Overview Hillcrest HealthCare System (HHS) is comprised of three hospitals in Tulsa and five regional hospitals, including Hillcrest Medical Center, Hillcrest Hospital South, Tulsa Spine & Specialty Hospital, Hillcrest Hospital Claremore, Hillcrest Hospital Cushing, Hillcrest Hospital Henryetta, Hillcrest Hospital Pryor, Bailey Medical Center of Owasso. Hillcrest also provides comprehensive primary and specialty care services through Utica Park Clinic and Oklahoma Heart Institute. Hillcrest Medical Center Hillcrest Medical Center is a 656-bed hospital that includes The Alexander Burn Center, The Peggy V. Helmerich Women’s Health Center, Kaiser Rehabilitation Center, the latest technology for the treatment of cancer, and the Oklahoma Heart Institute. POSITION SUMMARY The Director of Quality is responsible for the organizing and coordinating operational support for hospital Quality, and Medical Staff departments including scheduling and staffing, productivity, documentation, performance improvement, and policies and procedures and maintains administrative duties for reporting, productivity, compliance and budget. Additional requirements include the ability to support the executive officers in the implementation of new programs and services, budgetary compliance and liaison activities. Responsibilities Oversite of all survey activities the hospital maintains including accreditations, certifications, and licensure to ensures hospital operations continue Oversite of hospital staff that support the Peer Review/Professionalism Committees Organizing monthly interdisciplinary Quality Management Oversight Committee (QMOC) meetings with activities, per QMOC Calendar Receiving and reviewing all hospital quality improvement reports Presenting monthly/quarterly/annual quality reports to hospital leadership to included monthly medical executive committee meetings, hospital board meetings and other meetings as assigned. Working with hospital leadership team to ensure internal and external reporting requirements are met Works with CVO/MSO leadership to collaborate and provide local support of Medical Staff Office operations Has an intimate, working knowledge of hospital bylaws and works as a resource for hospital medical staff leaders when bylaws questions arise. Assists Medical Staff leaders and the Medical Executive Committee with development and implementation of medical staff quality improvement activities Leads the hospital team along with the Patient Safety manager in the performance of Root Cause Analysis processes Oversite of periodic quality related data entry, analysis and reporting Is the recognized leader for continuous quality improvement programs throughout the hospital. Attends hospital leadership meetings to include senior leadership meetings with hospital executives (CEO, COO, CNO etc.) and reports on local quality, safety, regulatory, medical staff processes as needed. Attends regular hospital Administrative Council and Clinical Service Line meetings. Serves as an intermediary between local hospital leaders and Health System Quality and Safety leadership. Leads the implementation of hospital quality and safety improvement programs. Qualifications Education & Experience Minimum of bachelor’s degree in nursing with valid state license required Master’s degree in a clinical or associated field preferred Additional certifications in quality, safety (CPHQ), and/or LEAN Six Sigma encouraged Leadership of Quality programs at a hospital level Experience with Safety Event Analysis processes 5 years of clinical experience required; 2 years of leadership experience preferred Knowledge, Skills & Abilities Proven leader who can develop positive relations with hospital clinical leaders to drive quality Demonstrate critical thinking, skills, scientific judgment and leadership in anticipating, delegating and planning Demonstrate a working knowledge of the principles of quality to include care that is Safe, Evidence Based, Patient Centered, Timely, Efficient and Equitable for all patients.