Director Quality and Regulatory

Director responsible for Quality, Regulatory, and Performance Improvement for Trinity Hospital and South Suburban Hospital.

Pay Range:

Major Responsibilities:

• Directs, organizes, and plans the site clinical and administrative functions of the ISO9001 Quality Management System, including Quality Management Oversight Committee, and its requirements.

• Responsible for monitoring performance improvement activity in accordance with system and site safety and health outcomes priorities.

• Provides leadership and oversight to external agency visits, including accreditation and certification surveys, state surveys, and other agency investigations.

• Serves as the hospital management representative and preparation agent for DNV and ISO surveys

• Responsible for management and oversight of the hospital physician and APC peer review program including the provision of data and case review for OPPE and FPPE related processes.

• Oversees the hospital contract management program, including maintenance of a hospital log and overall evaluation.

• Responsible for the hospital document management program, including policies, procedures, scope of service, and other key site documents.

• Performs human resources responsibilities for staff which include interviewing and selection of new employees, promotions, staff development, performance evaluations, compensation changes, resolution of employee concerns, corrective actions, terminations, and overall employee morale.

• Develops and recommends operating and capital budgets and controls expenditures within approved budget objectives.

• Responsible for understanding and adhering to the organization's Code of Ethical Conduct and for ensuring that personal actions, and the actions of employees supervised, comply with the policies, regulations and laws applicable to the organization's business.

Licensure, Registration and/or Certification Required:

• None Required.

Education Required:

• Bachelor’s degree in healthcare or related field.

Years of Experience:

• Typically requires 7 years’ experience in quality improvement.  Includes 3 years’ experience in leadership role.

Knowledge, Skills & Abilities Required:

• Advanced knowledge of quality improvement methodologies (i.e. Lean, Six Sigma)

• Analytical and statistical skills

• Clinical knowledge of care processes

• Proficiency with MS Office

• Facilitation skills; excellent verbal and written communication skills

• Proficiency with change management

• Proficiency with project management

Physical Requirements and Working Conditions:

• Ability to sit for extended periods of time.

• Ability to travel to other AAH locations.

• Exposed to normal office environment.

• Operates all equipment necessary to perform the duties of the job.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.

Our Commitment to You:

Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including:

Compensation

• Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training

• Premium pay such as shift, on call, and more based on a teammate's job

• Incentive pay for select positions

• Opportunity for annual increases based on performance

Benefits and more

• Paid Time Off programs

• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability

• Flexible Spending Accounts for eligible health care and dependent care expenses

• Family benefits such as adoption assistance and paid parental leave

• Defined contribution retirement plans with employer match and other financial wellness programs

• Educational Assistance Program

Note: Eligibility for programs listed above may depend on your FTE or status (e.g., full-time, part-time, per diem, temporary, etc.); please ask a Recruiter for more information during an interview.