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Executive Director, Quality Operations

Wellstar Shared Services • Marietta, GA • Leadership • 114826 • Days • Full-Time


This Executive Director of Quality Operations provides a leadership role, assuming responsibility for planning and coordinating efforts across the organization for the strategic and operational deployment of the WellStar Quality program. The ultimate goal of this position is to create competitive advantage through outcome improvements in key strategic processes. Success is measured in five key dimensions of quality (Keep Me Safe, Help Me Stay Well, Provide Me with the Right Care, Help Me Navigate my Care, Treat me with Respect) with specific goals in each. The scope of the role includes, but is not limited to:

Selection, preparation and presentation of education, data, and actionable information for Board and System Quality Committee level audiences;
Maintaining centralized governance and standards for quality performance improvement initiatives and projects;
Advising and guiding quality improvement teams that are system-wide and/or decentralized throughout the organization;
Knowledge of criteria for Performance Excellence/ Baldrige Excellence framework and leveraged to support successful hospital and system adoption of Baldrige Framework.
Expert knowledge of Governor's Sterling Award & Sustained Excellence criteria and successful achievement.
Drive for Quality and Focus on Results for Baldrige Excellence.
Implements, coordinates, and monitors Continuous Improvement projects to support and improve operational processes within the Health System.
Provides leadership and guidance in the implementation and improvement of system process improvement efforts.
Maintains documentation of Quality Performance Excellence initiatives.
Leads, coaches, and instructs process owners and teams in defining, documenting, measuring, analyzing, improving, and controlling business processes related to Quality Performance Excellence.
Spread of successful improvement efforts across the organization, assuring systems sustainability of quality performance excellence

In conjunction with the VP of Clinical Outcomes and the VP of Medical Outcomes, the Executive Director develops and implements the long-term and short-term strategy for Safety and Quality at WellStar. It is expected that the Executive Director stays abreast of quality and safety activities at the national level through engagement with institutions such as the National Associate for Healthcare Quality (NAHQ) and the Institute for Healthcare Improvement (IHI) and researches and advises on best practice solutions. Identification and promotion of evidence based practice, as well as the use of Lean Management System and Lean Production System methods are required.

This Executive Director will recognize and respond fluidly to varying situations that may require: influencing teams to adhere to standards, facilitating spread of best practices and/or innovation and design of creative solutions. This role facilitates multi-entity coordination of clinical quality improvement initiatives, requiring strong project management and critical thinking skills. Frequent collaboration is required with medical staff, senior administration and department leaders to identify, analyze, and trend clinical and quality issues and implement successful solutions. This role necessitates policital acumen, situational awareness and a demonstrated ability to lead individuals and teams at all levels of the organization through influence.


Core Responsibilites and Essential Functions

  • Leadership: Provide centralized direction, governance and leadership for major projects and programs related to Quality Performance Excellence
    * a.In conjunction with the VP of Clinical Outcomes and the VP of Medical Outcomes develop and implement the long-term and short-term strategy for Safety and Quality at WellStar.
    * b.Lead operations and innovations around the System Quality Performance Excellence Improvement Plan, aligning Lean Methodology with the Baldrige excellence framework.
    * c.Ensure governance level Quality reports and communications support the Board of Trustee and delegated Board committees to meet the fiduciary responsibilities.
    * i.Provide critical data an information transparently and at an appropriate level to facilitate effective governance oversight.
    * ii.Distill information in a manner that resonates with both clinical and lay Board members.
    * iii.Meet all regulatory & accreditation requirements with respect to periodic quality and safety related reports.
    * d.Serve as liaison to all local level business units and entities for oversight and advising on quality improvement projects and their alignment with system goals.
    * i.Provides direction to decentralized resources and build meaningful relationships with sites
    * e.Co-lead interfacility, service line and other collaboration meetings that identify improvement initiatives needed or desired and report key decision points to all governing bodies, such as the main quality governance leadership team
    * i.Identifies correct local level teams to lead and run specific quality initiatives identified
    * f.For high priority, complex programs, serves as champion or sponsor to cross-functional teams. Works closely with Operations, Quality, and other departments to ensure project priorities and decisions are consistent between teams and corporate strategic plans.
    * i.Develop effective working relationships and efficient cross-functional processes with Medical Management, Utilization and Care Management, Provider and Member Services, Claims and Finance, and the Information Systems
    * g.Provide oversight of Quality and Safety Awards and applications across the system.
  • Growth: Provide advisory coaching and educational training on process improvement projects, methodology, tools and standards
    * a.Partners with leadership in the Lean Transformation office to implement and reinforce Lean process improvement and management tools as needed for quality leadership and teams.
    * b.Integrate other appropriate improvement and High Reliabilty strategies and tools.
    * c.Develops patient-centered programs that promote Quality efforts and results. Focusing on the core quality principles, which include: Keep me safe, Help me stay well, Help me navigate my care, Treat me with respect, Provide me with the right care.
    * d.Represents WellStar and participates in local, regional and state collaborations, forums and meetings as requested to ensure optimal understanding of industry trends and synergies.
    * e.Engage a diverse set of external stakeholders that would be beneficial to the continued growth and continuous improvement activities
  • Other duties
    * a.Oversight of quality work at the System and Business Unit/Facility Level
    * b.Assists with hiring and oversight of onboarding within the Clinical Outcomes Team and System Safety and Quality Department
    * c.Assists with onboarding and coaching of Business Unit/Facility Quality Department Staff in regards to system quality standards.
    * d.Monitoring existing processes and effectiveness within the System Safety and Quality Department and develop improvement strategies where necessary.
    * e.Monitoring existing processes and effectiveness within the Facility/Business Unit Safety and Quality Department and develop improvement strategies where necessary.
    * f.Regularly prepares proposals and presents ideas in formal meetings to senior leadership and Board members as needed
    * g.Maintain strict confidentiality of employee and organizational information in accordance with HIPAA and State privacy regulations
    * h.Provides an open environment and promotes teamwork. Acts as a catalyst to remove organizational barriers.
    * i.Coordinates other team members, systems, and processes to achieve organizational goals in accordance with organizational policies and practices
    * j.Other duties as assigned

  • Required for All Jobs

  • Performs other duties as assigned
  • Complies with all WellStar Health System policies, standards of work, and code of conduct.

  • Qualifications

    Required Minimum Education

  • Master's Degree Required

  • Required Minimum Experience

  • Experience: Minimum three (3) to five (5) years with specifically leading clinical quality performance/process improvement efforts in a health system setting (physicians and/or hospitals). Required and
  • Minimum 10 years experience in project management and/or performance improvement initiatives.

  • Required Minimum Skills

  • This role will focus on creating partners across the organization and being impactful along broad indirect reporting relationships.
  • It is important that this person has the ability to engage and lead other leaders across the Quality framework.
  • This position?s responsibility is focused on managing overall governance and methodology of Quality Performance Improvement efforts for the organization.
  • Superior critical thinking, analytical and problem-solving skills
  • Exceptional interpersonal, team-building and communication skills
  • Ability to build consensus and foster change in organizational setting
  • Professional competence in applications such as: Microsoft Office Suite, Microsoft 365, Project Management tools, EPIC, etc.,
  • Expert skills in performance improvement including but not limited to Lean, PDSA, etc.
  • Commitment to personal and professional growth
  • Sense of responsibility to self, team and project
  • Outstanding integrity, initiative, creativity, and passion
  • Ability to work in an ambiguous environment
  • Ability to work cohesively with the Technology department counterparts

  • Required Minimum License(s) and Certification(s)

  • Lean Certification and/or PMP certification, Required
  • Baldrige or Sterling Examiner Certification Required
  • Certified Professional in Healthcare Quality (CPHQ) Required

  • Additional Licenses and Certifications

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