Director Quality & Regulatory Oshkosh
Company: Advocate Health
Location: Oshkosh
Posted on: April 20, 2024
Job Description:
Provides leadership, development, and oversight of the site's
Quality Management System and health outcomes for Aurora Medical
Center Oshkosh and the new Fond du Lac site. This individual
collaborates with operational leaders to ensure that the highest
level of quality of patient care is delivered through data
analysis, performance improvement activities and initiatives, the
Quality Management System, and compliance with regulatory
requirements and accreditation agencies. This position serves as a
key role in facilitating key quality and regulatory communication
to the site executive leadership team and medical staff.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 managementPhysical 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.
Keywords: Advocate Health, Oshkosh , Director Quality & Regulatory Oshkosh, Executive , Oshkosh, Wisconsin
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