Job Description

The Director of Quality and Performance Improvement‘s overall responsibility is to develop and direct an effective, comprehensive system-wide Performance Improvement Program. The Director of Quality and Performance Improvement provides administrative, organizational, clinical, and educational leadership in a manner consistent with SJH’s mission, vision, and values as well as the principles outlined in SJH’s foundational priorities and strategic plan.

The Director of Quality and Performance Improvement functions as a dynamic leader of the SJH multidisciplinary leadership team to determine process improvements that will improve patient care processes and outcomes. This includes responsibility of daily operations and activities related to patient care processes and outcomes that impact quality of care, community perception and potential for revenue loss/gain. Scope of practice will include, but is not limited to the Provider Peer Review process, CMS inpatient and outpatient hospital reporting, (inclusive of value-based programs), Leapfrog Hospital Survey, NJ DOH quality reporting, proportionate shared programs, and Pay for Reporting incentive programs.

The Director of Quality and Performance Improvement serving as a the leader of quality improvement initiatives will identify opportunities for improvement in care, upon access, during treatment, and transition of care accomplished through the collaborative efforts of multidisciplinary teams, Clinical Services, Ancillary Support Services, and Contracted Services.

These opportunities will be identified by utilizing data analytics and to facilitate improvement of clinical and operational outcomes in order to implement process change/redesign, resource alignment or policies that improve patient care and/or services.

• This position offers a unique opportunity for an articulate innovator and effective change agent to work with clinicians, researchers, clinical and operational staff to develop and lead (strategic plan).

Qualifications

• Masters degree preferred
• Registered Nurse (RN) license required
• Previous experience in leading Performance Improvement initiatives with a focus on process oriented activities that present opportunities for improvement
• Previous experience with Leapfrog criteria and survey submission process
• Certified Professional in Healthcare Quality (CPHQ) required
• Seven (7) years related experience of which five (5) years must be in a leadership role focused on care process indicators and outcome.
• Strong understanding of clinical operations
• 5 years of diverse clinical experience.
• Experience with a variety of methods and tools that support Performance Improvement activities.
• Strong understanding of Center for Medicare and Medicaid Services (CMS) Inpatient and Outpatient reporting programs and requirements
• Able to interpret legislative policy as it applies to CMS, NJDOH Quality monitoring and reporting
• Strong knowledge base of pay for performance programs
• Comprehensive knowledge of administrative data and implications of quality reporting
• Requires ability to perform complex statistical analysis and interpret data analytics
• Strong working knowledge of informatics and decision support techniques
• Familiarity with HCAHPS and other survey instruments that assess patient perspective of care
• Demonstrated track record of highly developed problem-solving skills.
• Requires the ability to manage programs and projects.
• Requires demonstrated excellence in interpersonal and written communication skills
• Working knowledge of NJDOH reportable safety events, patient safety initiatives, HRO facilitation, and DNV/ISO accreditation to support Patient Safety/Accreditation and Risk Management department activities

St. Joseph’s Health is recognized for the expertise and compassion of its highly skilled and responsive staff. The combined efforts of the organization’s outstanding physicians, superb nurses, and dedicated clinical and professional staff have made us one of the most highly respected healthcare organizations in the state, the largest employer in Passaic County, and one of the nation’s “100 Best Places to Work in Health Care”.

Benefits Eligibility : (Full-time and Part-time Employees-over 20 hours a week)

• Competitive salary*
• Robust benefits with health, dental, Rx and vision plans
• 403b retirement plan options with company match**
• Health & Wellness*
• Non-Profit Health System – eligible for Federal Student Loan Forgiveness
• PTO, and paid holidays
• Tuition reimbursement
• Employee Assistance Program
• LTD : Long Term Disability
• Life Insurance Options
• Onsite Day care Program
• Available for Per Diem Employees and Part-time Employees working under 20 hours per week.
• 403b Company Match not applicable for Per Diem Employees and Part-time Employees working under 20 hours per week.

Pay transparency : St. Joseph’s Health provides a salary range to comply with New Jersey Law. The rate of pay for each position will be determined based on a variety of factors including the candidate's relevant experience, qualifications, skills, etc.” The salary range does not include incentives, differential pay or other forms of compensation.

About The Team

St. Joseph’s University Medical Center is an academic tertiary care medical center and state designated trauma center, located on the Paterson campus, regularly accepts referrals of difficult or unusual cases from other hospitals and physicians and performs both complex and routine procedures.

The Medical Center offers a full complement of specialty and subspecialty services including ambulatory, behavioral health, cardiovascular, emergency/trauma, internal medicine, neuroscience, oncology, orthopedic/spine, rehabilitation, surgical specialty, women’s health, imaging and pediatrics.

The nursing team at St. Joseph’s University Medical Center, which includes St. Joseph’s Children’s Hospital, has held the Magnet Award for Nursing Excellence, the profession’s highest honor, since 1999. They are also recipients of the prestigious 2010 Magnet Prize - one of only 8 Magnet-designated hospitals to ever receive The Magnet Prize, and the only one worldwide to receive the 2010 award.

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