Company Description

At Northwestern Medicine, every patient interaction makes a difference in cultivating a positive workplace. This patient-first approach is what sets us apart as a leader in the healthcare industry. As an integral part of our team, you'll have the opportunity to join our quest for better healthcare, no matter where you work within the Northwestern Medicine system. At Northwestern Medicine, we pride ourselves on providing competitive benefits: from tuition reimbursement and loan forgiveness to 401(k) matching and lifecycle benefits, we take care of our employees. Ready to join our quest for better?

Job Description

The Program Director, Quality reflects the mission, vision, and values of Northwestern Medicine, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.

The Program Director, Quality is responsible for the operational oversight, strategy and management of the specified service line functions system-wide. Responsible for planning and coordinating all or a portion of the overall operations of the Quality program for a specific operating unit at the direction of the assigned Director, Quality. Provides leadership, resources, tools, and analytics to improve quality outcomes in specified service line.  Coordinates and leads the quality endeavor, coordinates with peers, and is responsible for implementation and follow up as outlined in the annual quality plan, ongoing priorities of leadership and quality committees, and compliance with relevant standards monitored by The Joint Commission (TJC) and other agencies. 

This position will advance the use of quality evaluation and improvement strategies to achieve key organizational goals in quality and patient safety.  The Program Director partners with administrative, physician, nursing, and ancillary leadership to advance the quality agenda through the development and implementation of plans and strategies that facilitate the achievement of strategic organizational goals.

Responsibilities:

Plans, directs, and manages the overall quality operations of the service line program(s) for their business units. Collaborates with physician, nursing, and operational leadership. In collaboration with the team, the Program Director, Quality is responsible for the following:

• Perform annual risk assessments
• Lead the development and implementation of the annual quality plan
• Actively prepare for and engage in relevant service-line-specific accreditation activities and surveys
• Provide quality support for payer center of excellence applications and processes

Implement effective quality planning

• Provide leadership to department heads and clinical chairs in designing quality plans, programs and policies, peer review and adverse event review, and best practices within their departments.  Lead the department to identify quality opportunities and concerns, in collaboration with the Vice President of Quality, Director of Quality and relevant operational Director(s).
• Support/facilitate the implementation of systems and processes that promote a fair and just culture, and improve patient care.
• Facilitate discussion and achieve consensus with senior operational and physician leadership regarding key quality and patient safety metrics and priorities
• May include collaborating to develop patient engagement strategies such as Patient Family Advisory Council

Regulatory Compliance

• Assure timely and accurate private and public reporting as required
• Assure compliance with service-line-specific Medicare Conditions of participation, Joint Commission standards, and other accreditation/licensure/ regulatory requirements (see: Competency/Performance expectations below)
• Oversee the creation, implementation, and tracking of effective corrective action plans

Provide leadership and operational implementation of assigned Clinical Quality activities

• Conduct detailed, sophisticated, accurate, timely, and comprehensive analyses of data at NMHC and outside NMHC (e.g. benchmarks, comparative data, CMS) to identify quality opportunities
• Develop, conduct, and implement improvement activities to achieve high quality & high-reliability healthcare. 
• Identify and utilize appropriate quality metrics to evaluate project or performance success based on stated purpose and needed outcomes.   
• Advance performance compared to appropriate external benchmarks and optimize process and outcome metrics.
• In collaboration with clinical operations, implement best practices which will improve quality outcomes within the organization
• Serve as organization expert on best practices, national and local trends and issues
• Coordinate organizational responses to regulatory standards related to quality such as Joint Commission, CMS, IDPH, and specialty-specific programs.
• Provide oversight for relevant CMS and other agency data submission and ensure compliance with data requirements (e.g. validation, etc.)
• Lead communication, teaching, modeling, process consultation and implementation of best quality practices

Support NM quality program

• Share quality activities across NMHC and coordinate collaborative NMHC quality efforts as assigned.
• Maintain a current understanding of quality theory, measures, methods, standards and regulatory requirements.
• Participate in the development, review, and revision of policies and procedures that affect quality.
• Maintain collaborative relationships with other departments including, but not limited to, Accreditation and Compliance, Risk Management, Patient Safety, Process Improvement, Clinical Documentation, and Nursing, Medical Staff, Pharmacy, Contracting and Payor Relations, and other disciplines.
• Continuously evaluate and improve the quality program based on internal needs and external requirements and standards. 

Support effective department operations and growth, and personal development

• Build strong interdisciplinary partnerships  
• Provide support to Nursing, Medical Staff, Laboratory, and all clinical areas
• Support, coach, teach, mentor, monitor and evaluate the work of others conducting quality work (as directed) and personally conduct, coordinate, facilitate, and participate in quality assessments, improvement efforts, committees, etc.
• Recruit, manage, mentor, coach, and develop staff as assigned, to optimal professional effectiveness and engagement.
• Oversee effective use of budget and other resources as delegated.  Supervise 1-2 staff.  Supervise projects with organizational impact, and manage intermittent staff assignments.
• Responsible for self-development and professional engagement, including knowledge of the literature and attendance at professional meetings, preparation of manuscripts, posters and presentations, involvement with local and national task forces as relevant

Qualifications

Required:

• Minimum 5+ years of relevant work experience
• Education

  • Bachelor’s degree in relevant field (RN,RPh, health administration, public health, etc.)

  • Master’s degree in relevant field (or equivalent experience and demonstrated ability).

• Quality evaluation and improvement experience, including leadership, in a relevant environment
• Self-driven and organized
• Demonstrated ability to rapidly and thoughtfully generate sound analysis, options and decisions
• Facilitation/presentation skills
• Proven ability to execute
• Proven analytical skills
• High level of energy and enthusiasm; able to energize others
• Excellent oral and written communication skills
• Excellent computer and data management/analytic skills
• Experience in facilitating quality measurement, analysis, improvement in a collaborative culture
• Working knowledge of performance improvement framework (i.e., DMAIC) and application of analytic tools

Preferred:

• 7+ years of relevant work experience
• Clinical Experience
• Experience in an academic medical center or system in a leadership role
• CPHQ certification or other evidence of commitment to professional development such as green belt, presentations/teaching, publication, etc

Additional Information

Northwestern Medicine is an affirmative action/equal opportunity employer and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status.

If we offer you a job, we will perform a background check that includes a review of any criminal convictions. A conviction does not disqualify you from employment at Northwestern Medicine. We consider this on a case-by-case basis and follow all state and federal guidelines.

Benefits

We offer a wide range of benefits that provide employees with tools and resources to improve their physical, emotional, and financial well-being while providing protection for unexpected life events. Please visit our Benefits section to learn more.