Summary
Job Description:
Job Title: Director of Quality
FULL TIME
The Director of Quality has operational and budgetary oversight for all areas of responsibility. Primary responsibilities include the development and maintenance of quality improvement program; coordination of performance improvement efforts to include patient experience, wound and ostomy care, infection prevention/control, pastoral care, peer review, and process excellence.
- Responsible for overseeing the operations of the department to ensure the provision of quality services and excellence in patient care.
- Serves as a leader, educator and mentor to physicians, directors and staff in promoting excellence in management of data, support quality of care, evaluation, outcomes management and in evidence-based outcomes across the organization.
- Responsible for overseeing the hospital quality improvement program. Ensures key processes and outcomes are tracked and reported in a timely and effective manner to physicians, staff, the hospital board and required external groups.
- Ensures compliance with all requirements of regulatory agencies associated with the quality department and keeps abreast of new and updated quality standards.
- Collaborates with other directors, physicians and staff to analyze interdepartmental data and support the development of action plans related to performance improvement initiatives.
- Participates in teams within the organization and system to achieve the goals of Baptist Healthcare System.
- Ensures that the staffing levels are maintained at an adequate level to meet the departmental needs. Monitors productivity levels and adjusts staff accordingly within budget
- Responsible for financial management of the quality department including budgetary analysis of clinical outcomes data, developing and monitoring the departmental operating budgets and management of human resources and capital.
- Maintains a system of communication with administration, staff, and serves on various committees as requested or delegated. Serves as a liaison between outcomes and administration/other departments/vendors, etc.
- Analyzes benchmarked data and develops reports for internal and external customers identifying practice patterns, and other areas of concern with recommendations for improvement as appropriate.
- Develop systems and processes for timely and accurate data collection.
- Analyzes and interprets data that facilitates clinical practice patterns, communicates findings, and actively participates in areas for process improvement, solutions and implementation of solutions that positively impact patient outcomes.
- Attends all required safety training programs and can describe his/her responsibilities related to general safety, department/service safety, specific job related hazards, and national patient safety goals.
Requirements:
- Master’s degree in nursing required (or will be enrolled in an accredited Master of Nursing program within one year of hire with degree completion within 3 years).
- 3-5 years of healthcare management experience
- 3-5 years of clinical healthcare experience
- Data management and data reporting experience required
- Holds a certification as Certified Professional Healthcare Quality (CPHQ) or obtains within two years of hire
- Proficient with computers, databases, and software programs.
Benefits: Full-Time 32 weekly hours (0.8 FTE) - 40 weekly hours (1.0 FTE)
- Health, Vision, Dental and Pet Insurance
- Life Insurance
- Short Term and Long-Term Disability and Life Insurance
- Identity Theft Protection
- Tuition Reimbursement up to $6,000 annually
- Company paid Maternity and Paternity Leave
- 5 days of Paid Time Off available upon hire
- Bereavement Leave (includes pets)
- PTO Sell Back Program
- Compassionate Leave Sharing Program (PTO Donation)
- Employee Support Fund, for employees in need of emergency financial support
- Retirement with Company Match
Skills Required
- Master's degree in nursing, or enrollment in an accredited Master of Nursing program within one year of hire with completion within three years
- 3-5 years of healthcare management experience
- 3-5 years of clinical healthcare experience
- Data management and data reporting experience
- Certified Professional Healthcare Quality certification, or obtaining it within two years of hire
- Proficiency with computers, databases, and software programs
What We Do
Founded in 1924 in Louisville, Kentucky, Baptist Health is a full-spectrum health system dedicated to improving the health of the communities it serves. The Baptist Health family consists of nine hospitals, employed and independent physicians, and more than 400 points of care, including outpatient facilities, physician practices and services, urgent care clinics, outpatient diagnostic and surgery centers, home care, fitness centers, and occupational medicine and physical therapy clinics. Baptist Health’s eight owned hospitals include more than 2,300 licensed beds in Corbin, Elizabethtown, La Grange, Lexington, Louisville, Paducah, Richmond and New Albany, Indiana. Baptist Health also operates the 410-bed Baptist Health Deaconess Madisonville in Madisonville, Kentucky in a joint venture with Deaconess Health System based in Evansville, Indiana. Baptist Health employs more than 23,000 people in Kentucky and surrounding states. Baptist Health is the first health system in the U.S. to have all of its hospitals recognized by the American Nursing Credentialing Center with either a Magnet® or Pathway to Excellence® designation for nursing excellence. Baptist Health’s employed provider network, Baptist Health Medical Group, has nearly 1,500 providers, including more than 750 physicians and more than 740 advanced practice clinicians. Baptist Health’s physician network also includes more than 2,000 independent physicians. Learn more at BaptistHealth.com.







