Summary Provides operational direction and guidance for Corporate Quality, Infection Prevention, Accreditation and Compliance including Environment of Care, Quality Data and Analytics. Works in close coordination with Chief Quality Officer in the implementation and deployment of comprehensive clinical quality and patient safety strategies, to include but not limited to, standardization of care, regulatory compliance and accreditation, and identification of best evidence-based practices in inpatient, outpatient, ambulatory, and post-acute settings, when appropriate.Facilitates change through the implementation of quality care delivery models, including care coordination, enhanced patient outcomes, and improved financial performance linking reimbursement to quality goals and measurements. Implements educational offerings and leads process improvement projects/activities. Works in partnership with system and entity leaders, physician constituents, clinical leaders, and interdisciplinary care teams, and other key stakeholders to create and sustain a culture of quality and safety, performance transparency, teamwork, measurement, and accountability in order to implement clinical quality transformation throughout Baptist and within all care settings.Supports Baptist's mission, vision, values, and principles. Responsibilities • Provides operational guidance in the development, implementation, and evaluation of comprehensive quality improvement programs to enhance patient safety, achieve better health outcomes, and comply with regulatory standards. • Assembles a high performing and engaged Corporate Quality team dedicated to teamwork, communication, and collaboration in the deployment, alignment, and accountability of programs, service delivery, and operational effectiveness. • Participates in the development of quality measurement systems and other advanced technologies to strengthen Baptist's data capabilities and drive operational efficiencies and outcome improvement. Works in close collaboration with Chief Quality Officer, system clinical leaders, entity CEOs, BMG CEO, physician leaders, and other key stakeholders to validate organizational direction. • Researches, evaluates, and recommends evidence based "best practices" focusing on value based care delivery and reimbursement methodologies which link to improved quality of care, enhanced patient outcomes and experience, and reduction in healthcare costs. • Works collaboratively with interdisciplinary teams to monitor quality and patient safety performance and improvement efforts throughout the Baptist system. Works in partnership with hospital CEOs, CMOs, CNOs, clinical teams, physicians and the quality directors to drive standard data reviews and to identify problem solving opportunities through root cause analysis and continuous improvement methodologies. • Works with Chief Quality Officer, clinical teams, physicians, and other key stakeholders, as appropriate, to identify care delivery gaps and develop/implement internal and external care coordination strategies focusing on defined populations. Monitors and evaluates quality improvements and health outcomes while driving cost efficiencies and resource utilization. • Develops and monitors key performance indicators (KPIs) and quality metrics to assess the effectiveness of quality improvement and patient safety efforts, making adjustments as necessary to meet organizational goals. • Leads multidisciplinary teams in the analysis of incident reports, root cause analyses, and failure mode effects analyses to identify systemic vulnerabilities and implement corrective actions. • Utilizes advanced methodologies to analyze clinical data, identify trends, and implement evidence-based interventions to drive improved patient outcomes and healthcare delivery efficiency in acute care, outpatient, ambulatory, and post-acute care settings. • Designs and implements patient safety initiatives, such as infection control measures, medication safety protocols, and patient identification processes, to minimize the risk of harm to patients. • Collaborates with providers, organizational leaders, and team members to foster/support a "just" safety culture so that safety concerns are readily communicated/reported without fear of retribution. • Works collaboratively with Corporate Legal, Risk Services, and other key stakeholders to analyze trends in litigation and adverse events in order to develop strategies to minimize legal risks, deploy action plans, and measure patient safety improvement efforts. • Facilitates the accreditation process by ensuring that all aspects of patient care meet the standards set by relevant accrediting bodies, to include but not limited to, preparing for site visits, conducting audits, and managing the submission of necessary documentation. • Develops/implements/conducts training and/or educational offerings on an array of pertinent quality and patient safety topics, process improvement opportunities and/or progress, data, analytics, and/or trends, and compliance/accreditation updates. • Provides other duties as directed or assigned. Requirements, Preferences and Experience • Bachelor's Degree required.A minimum of 7 years outcome, oriented experience in healthcare operations with 5 years quality management experience within a large to midsize health care system. Master's Degree preferred. Clinical License or Designation required. • Knowledge of current healthcare legislation and policies, patient safety protocols, quality improvement methodologies, financial/reimbursement trends, and regulatory standards to minimize potential compliance risks, sanctions, and/or financial penalties. • Ability to analyze, interpret, and communicate metrics/complex quality and financial data in a clear, concise manner to a number of different audiences/key stakeholders representing a variety of care settings. • Experience identifying quality performance drivers relevant to related penalties and reimbursement, creating action plans and producing measurable results to reduce penalties and obtain reimbursement. • Possesses experience working with Electronic Medical Record builds and clinically relevant report creation to improve clinical documentation, data capture, and clinical workflows to reduce PSIs, HAIs, CMS complications, mortality, readmissions, and improve HCAHPS.Epic experience strongly preferred. • Experience with regulatory agency investigations related to patient complaints, implant or equipment recalls, agency reporting requirements, and appropriate response resulting in remediation and implementation of processes that mitigate future safety events. • Knowledge of and experience with continuous process improvement methodologies and tools.Ability to apply change management strategies and methods in support of an array of quality initiatives. • Possesses clear understanding and experience regarding the deployment of care coordination strategies, interventions, and tactics to improve both efficiency and quality. • Must possess excellent interpersonal and organizational skills with ability to establish/build internal and external relationships.Strong group facilitation and conflict management skills and a demonstrated ability to unite individuals around a common vision/goal. About Baptist Memorial Health Care At Baptist, we owe our success to our colleagues, who have both technical expertise and a compassionate attitude. Every day they carry out Christ's three-fold ministry-healing, preaching and teaching. And, we reward their efforts with compensation and benefits packages that are highly competitive in the Mid-South health care community. For two consecutive years, Baptist has won a Best in Benefits award for offering the best benefit plans compared with their peer groups. Winners are chosen based on plan designs, premiums and the results of a Benefits Benchmarking Survey. At Baptist, We Offer: + Competitive salaries + Paid vacation/time off + Continuing education opportunities + Generous retirement plan + Health insurance, including dental and vision + Sick leave + Service awards + Free parking + Short-term disability + Life insurance + Health care and dependent care spending accounts + Education assistance/continuing education + Employee referral program Job Summary: Position: 20379 - System Director-Quality Facility: BMHCC Corporate Office Department: HS Quality Corporate Category: Quality, Compliance & Safety Type: Non Clinical Work Type: Full Time Work Schedule: Days Location: US:TN:Memphis Located in the Memphis metro area REQNUMBER: 27612