The Corporate Director of Quality is responsible for providing visionary guidance to the current and future needs of the PAM Health hospitals in Quality, Infection Control, and Regulatory Services.  Acts as a motivational servant leader, inspiring performance and a strong message of communication and teamwork.  Works in conjunction with the Chief Quality Officer reviewing current and future needs of PAM Health.  Coordinates with hospital leadership to foster a culture of safety and planning activities to improve patient care and organization functions.  Provides direction and assistance to the local hospital leadership for quality and regulatory measures. Performs other related duties as assigned or requested.  This is an exempt position and will require frequent travel (up to > 95% of the time). 

• Works in conjunction with Chief Quality Officer to review, modify, or create policies that support and guide the infection control and quality care of PAM Health hospitals following CMS, State, and TJC, or CIHQ regulations.
• Ensures standardization throughout all PAM Health Hospitals.
• Works in conjunction with Chief Quality Officer to review monthly quality indicators and reviews the improvement/action plans or processes to correct and improve quality and regulatory indicators.
• Works in conjunction with hospital clinical staff to assist in implementing quality and regulatory metrics in specialty programs such as but not limited to: Rehab, Wound Care, Respiratory, Critical Care, etc. 
• Oversees licensure and accreditation processes to assure compliance with CMS, State, and TJC or CIHQ standards in order to maintain licensure and accreditation.
• Oversees quality infrastructure for new builds and acquisitions to assure compliance with CMS, State, and TJC or CIHQ standards for a successful opening.
• Works in conjunction with Corporate Director of Quality and Infection Control and infection control and quality of the hospitals to assist with the development and oversight of quality and infection control education.
• Ensures quality and infection control databases and licensure are in place for new builds and acquisitions.
• Collaborates and coordinates travel with the Chief Quality Officer.
• Provides written reports from site visits to the hospital CEO, Director of Quality, Regional President, Chief Clinical Officer, and the Chief Quality Officer to include recommendations for educational opportunities or changes to processes.
• Recommends long-range plans for the quality, infection control, and regulatory services to support PAM Health objectives
• Weekly calls with the Chief Quality Officer to review hospital data, action plans, and meet PAM Health objectives.

Leadership

• Executive Presence: Maintains highest level of professionalism when representing PAM Health both on and off site.
• Leadership: Motivates others. Accepts responsibility. Develops trust and credibility. Expects honest and ethical behavior of self and staff.
• Inclusiveness: Promotes cooperation, fairness and equity; shows respect for people and their differences; works to understand perspectives of others; demonstrates empathy; brings out the best in others and in his/her team.
• Managing Staff: Coaches, evaluates, develops, and inspires staff. Sets expectations. Recognizes achievements. Effectively manages conflict. Aligns department goals with company goals. Provides feedback, group leadership. Delegates appropriately. Evaluations completed on time.
• Stewardship and Resource Management: Demonstrates accountability and sound judgment in managing company resources. Appropriate understanding of confidentiality and company values. Adheres to and supports company policies, procedures and safety guidelines
• Problem-Solving: Identifies problems, involves others in seeking solutions. Conducts appropriate analysis. Searches for best solutions. Effectively and efficiently implements appropriate response to correct problem. Responds promptly and effectively to new challenges.
• Decision-Making: Makes clear, consistent decisions. Acts with integrity in all decisions. Distinguishes relevant from irrelevant information. Makes timely, appropriate decisions.
• Strategic Planning and Organizing: Understands company vision and aligns priorities accordingly. Measures outcomes. Uses feedback to redirect as required. Evaluates alternatives. Appropriately organizes complex issues to desirable resolution.
• Communication: Clearly and effectively shares information. Connects with peers, subordinate employees and all customers. Actively listens. Demonstrates effective oral and written communication skills. Negotiates effectively.
• Quality Improvement: Strives for efficient, effective, high quality performance in self and the department. Delivers timely and accurate results. Resilient when responding to matters that are challenging. Takes initiative to make improvements
• Teamwork: Encourages cooperation and collaboration. Builds effective teams. Works in partnership with others. Is flexible. Responsive to the needs of others.
• Personal Development: Maintains up-to-date skills through involvement with professional organizations or continuing education.

Customer Service

• Maintains the highest level of customer service via courtesy, compassion and positive communication.
• Promotes the mission and vision of PAM Health within the work environment and the community.
• Respects dignity and confidentiality by adherence to all applicable policies and procedures.

Health and Safety

• Works in a manner that promotes safety; wears clothing appropriate to the performance of the job.
• Follows universal precautions as appropriate for position; complies with Employee Health requirements for continued employment
• Reports unsafe practices to management.
• Knows own role in case of an emergency.

Infection Control Responsibilities

• Assures coordination of the company-wide infection control program consistent with the policies, procedures, and guidelines of PAM Health.
• Initiates the evaluation of the company-wide infection control plan.
• Assures monitoring for compliance with company-wide infection control related policies, procedures, and regulatory body requirements.
• Assures monitoring of infectious diseases present in the hospital population, mode of transmission, and recommended treatment.
• Assists with education of all employees regarding handwashing, standard precautions, and other appropriate infection control related information.
• Creates and collaborates the hospital educational programs on health, safety, hazardous waste, etc.
• Assures appropriate reporting activities are completed.

Education and Training:  Current licensure as a Registered Nurse by the Board of Nurse Examiners of the state of residence.  Bachelor’s degree required.  Master’s degree in Nursing, Health Administration or related field preferred.  Knowledge of various approaches for improvement TPS, Lean, PDSA required.

Experience: Minimum of five (5) years of experience in quality leadership role required.  Minimum of three (3) years of healthcare administration experience in multi-facility preferred. 

Knowledge, Skills, and Abilities:

• Strong quality, leadership, and management skills along with a high level of initiative and creative problem solving.
• Ability to effectively lead a project
• Ability to effectively express ideas and views when speaking or writing for groups, hospital managers, personnel, and patients/family members.
• Ability to write reports, memoranda, etc.
• Cognitive ability to gather and analyze data and prepare reports.
• Ability to evaluate statistical data and to make various computations in planning departmental operations and budgets.
• Organizational ability to direct and motivate professional and non-professional staff in performance of all activities.
• Capacity to relate to people in a manner to win confidence and establish support.
• Organizational skills to prioritize work and use time effectively with flexibility to adjust to changing priorities and the various details of the job.
• Competence in Word, Excel, Power Point, Outlook and other computer programs.
• Licensed and able to drive an automobile.
• Able to travel using publicly available air and ground transportation.