EXECUTIVE DIRECTOR OF QUALITY OUTCOMES - UNIVERSITY OF NEW MEXICO HOSPITAL

Relocation Assistance Available

Minimum Offer

$ 65.70/hr.

Maximum Offer

$ 105.07/hr.

Compensation Disclaimer

Compensation for this role is based on a number of factors, including but not limited to experience, education, and other business and organizational considerations.

Department: Professional Service Admin

FTE: 1.00
Full Time
Shift: Days

UNM Health is New Mexico's only Level I Trauma Center—we care for patients with the most complex conditions from across the state. Additionally, we are the first NIH-designated Comprehensive Cancer Center and award-winning Advanced Care Stroke Center. UNM Health providers specialize in over 150 areas of medicine and employ over 7,000 professionals. Together, we receive 900,000 outpatient visits, 22,000 surgical cases and 100,000 emergency room visits each year. UNM Health provides the highest quality of care for more than 200,000 New Mexicans each year. In 1952, UNM Hospital was built on Native American grounds, with the promise to provide culturally competent and inclusive care to all New Mexicans. Since then, UNM Health has followed through with their mission of accessible, affordable care. UNM Health provided over $44 million in charitable care and financial assistance for services not covered by insurance or federal programs in 2018.

Position Summary:
Direct, plan, implement and monitor a strategic approach that advances the culture of safety and ensures the highest quality of clinical care delivery. Responsible for the ongoing development, direction, supervision and administration of the following departments and programs: Quality Outcomes; Quality Report Cards; and Epidemiology. Assure quality of care, cost effectiveness and optimal performance of personnel. Ensure adherence to Hospitals and departmental policies and procedures. No patient care assignment.

Detailed responsibilities:
* DIRECTION - Provide guidance, mentorship, and leadership to managers and staff
* BUDGET - Provide leadership in preparing budgets with managers and medical directors
* STAFF DEVELOPMENT - Establish competencies, training sessions, education programs for staff and managers; promote staff satisfaction and recognition activities
* ANALYSIS - Conduct regular or continual analysis of staffing, quality assurance, management review, budget reviews and performance evaluations
* IMPROVEMENTS - Recommend changes for improvement in program content and in short/long-range planning in order to maintain competitiveness in the healthcare market
* EDUCATION - Educate medical staff, managers and Health Sciences Center staff in monitoring, evaluating and improving clinical quality of care and regulatory compliance
* RESOURCES - Coordinate and evaluate the use of resources and services in a quality-conscious, cost effective manner and collaborate with appropriate providers to ensure effective, quality outcomes
* SUPERVISION - Develop efficient organizational structure. Supervise employees and select, terminate, train, educate, correct deficiencies, perform appraisals, issue discipline, counsel, schedule work assignments; encourage staff teamwork and growth initiatives
* DEVELOPMENT - Enhance professional growth and development through participation in educational programs, reading current literature, attending in-services, meetings and workshops
* PATIENT SAFETY 1 - Follow patient safety-related policies, procedures and protocols
* PATIENT SAFETY 2 - Demonstrate proactive approach to patient safety by seeking opportunities to improve patient safety through questioning of current policies and processes
* PATIENT SAFETY 3 - Identify and report/correct environmental conditions and/or situations that may put a patient at undue risk
* PATIENT SAFETY 4 - Report potential or actual patient safety concerns, medical errors and/or near misses in a timely manner
* PATIENT SAFETY 5 - Encourage patients to actively participate in their own care by asking questions and reporting treatment or situations that they don't understand or may "not seem right"
* PATIENT SAFETY - Develop and oversee implementation and maintenance of a strategic plan for patient safety; create, implement and maintain a structure that optimizes organizationl learning secondary to medical errors and adverse events
* STRATEGIC PLANNING - Assist in the strategic planning of both short- and long-range plans to include participation in the development of the Quality Assurance Performance Improvement (QAPI)
* QUALITY OPERATIONS - Ensure effective department structure and operations; manage department budget and resources; support effective teamwork, collaboration and growth across department staff
* LEADERSHIP - Partner with the Chief Quality & Safety Officer, Associate Chief Safety Officer, and Associate Chief Quality Officer to operationalize the hospital’s quality and safety strategy
* LEADERSHIP - Lead management of and regularly review the organizational quality improvement portfolio, ensuring alignment with institutional priorities and appropriate allocation of quality resources
* LEADERSHIP - Integrate health equity considerations into quality improvement initiatives, ensuring disparities in outcomes and access are identified and addressed within improvement work
* PI INFRASTRUCTURE - Oversee the design, execution, and monitoring of institutional performance improvement (PI) initiatives; ensure projects are conducted using a standardized improvement methodology : provide direct coaching and feedback to project leaders and clinician champions regarding improvement design, execution, and sustainability: ensure clinical and operational perspectives are triangulated in project design through collaboration with clinician and nursing leaders
* PATIENT SAFETY SYSTEM - Lead the operational management of the patient safety event reporting and communication and resolution program
* PATIENT SAFETY SYSTEM - In collaboration with the ACSO, ensure incidents, near misses, and adverse events are systematically reviewed and translated into organizational learning
* PATIENT SAFETY SYSTEM - Develop and maintain structured learning pathways for safety events (e.g., mortality review, serious safety event review, focused learning reviews)
* PATIENT SAFETY SYSTEM - Partner with Risk Management to ensure effective root cause analysis processes and follow-through on corrective actions
* IPC - Provide executive oversight and ensure the Infection Prevention and Control (IPC) program is fully resourced, aligned with organizational safety goals, and supported with appropriate expertise
* IPC - Collaborate with IPC leadership in integrating IPC improvement efforts with the hospital’s Quality & Safety strategic plan, ensuring data drives action and organizational learning
* IPC - Partner with IPC leadership in ensuring compliance with Joint Commission, CMS, CDC, and state IPC standards, including annual infection risk assessments and core IPC practices
* COMMITTEE GOVERNANCE - Provide operational leadership for the hospital’s quality governance committee structure; serve as operational lead for the Quality governance structure in partnership with the Associate Chief Safety Officer and Associate Chief Quality Officer
* COMMITTEE GOVERNANCE - Maintain the integrity of the quality committee ecosystem, including: clarifying committee scopes and decision rights, ensuring effective information flow between committees, minimizing redundancy and duplication of work, ensuring issues are escalated appropriately
* COMMITTEE GOVERNANCE - Prepare and present updates regarding Quality priorities and improvement progress to the Quality Executive Committee at regular intervals
* COMMUNICATION - Ensure consistent communication of quality and safety priorities, progress, successes, and challenges across the organization; develop mechanisms to cascade information from executive committees to operational teams
* LEARNING - Promote organizational learning by sharing improvement insights, safety learnings, and best practices
* DEVELOPMENT - Lead continuous professional development initiatives within the Quality Outcomes department, including training in quality improvement methodologies and patient safety science
* DEVELOPMENT - Promote horizontal knowledge sharing across the department to build institutional capability and ensure continuity of expertise; foster a culture of learning, critical inquiry, and methodological rigor among quality staff
* COLLABORATE - Build strong collaborative relationships with: nursing executive leadership, clinical and operational department/ service leaders, community engagement and patient relations, risk management
* COLLABORATE - Partner with executive director nursing colleagues and other operational leaders to ensure quality initiatives are embedded within clinical operations

Qualifications

Education:
Essential:
* Master's Degree
Nonessential:
* Doctorate Degree
Education specialization:
Essential:
* Related Discipline
Nonessential:
* Related Discipline

Experience:
Essential:
4 years directly related experience

Nonessential:
Management experience in quality management

Credentials:

Physical Conditions:

Light Work: Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly (Constantly: activity or condition exists 2/3 or more of the time) to move objects. Physical demand requirements are in excess of those for Sedentary Work. May require walking or standing to a significant degree or requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or may require working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of materials is negligible.

Working conditions:
Essential:
* Sig Hazard: Chemicals, Bio Hazardous Materials req PPE
* Subject to an annual contract and performance appraisal
* Tuberculosis testing is completed upon hire and additionally as required