Position Description – Director, Quality Improvement and Patient Safety
Stanford Hospital & Clinics

Our highly prestigious client, Stanford Hospital & Clinics (SHC) is known worldwide for advanced patient care, particularly for the treatment of rare, complex disorders in areas such as cardiac care, cancer treatment, neurology, neurosurgery and organ transplants.  Stanford Hospital includes 611 licensed beds.  The clinics offer care in more than 100 specialties, including cancer, neurology, surgery and organ transplantation. 

Patients come to Stanford from all over the Western United States and the world, often for specialized procedures unavailable elsewhere.  In recognition of excellent care, the hospital and physicians consistently rank among the top in the nation in surveys by consumers and health care professionals. In July, 2002, Stanford was named to the Honor Roll of America's Best Hospitals by U.S. News & World Report.  The Hospital was ranked #14 out of 100, in 2004.

Founded in 1991, Lucile Packard Children’s Hospital (LPCH) is a 256-bed non-profit hospital devoted entirely to the care of babies, children, adolescents and expectant mothers.  The state-of-the-art, main facility is located on the Stanford University campus.  LPCH is affiliated with the Stanford University Medical Center and many of its doctors also serve as professors at the Stanford University School of Medicine.

Management

An overview of top management of the hospital shows an exceptional blend of clinical, operational and business expertise in the field of acute and specialty care and services.  Underlying the management team's skill-set is a passionate, deep-seeded and visionary commitment to excellence, innovation and growth.  The style of management and the organizational culture of excellence are deeply rooted in teamwork and mutual support. 

The level of teamwork and support among the management staff is extraordinarily high and remarkably effective.  This group of Managers and Directors, with their collaborative style and complete commitment to the mission, is the heart of the department’s success.  It is readily apparent that the management team consistently emphasizes teamwork, individual achievement and making the job fun.

To complement the management team, an individual must be able to blend their individual success into that of the entire team and share in the commitment and the satisfaction of taking care of the healthcare needs of the community.

Position Description

Director of Quality Improvement/Patient Safety (DQI) provides the overall leadership and direction for implementation of the Stanford Hospital and Clinics’ Quality Management Plan.  This responsibility includes providing a planned, systematic, organization-wide approach to identifying, designing, measuring, prioritizing and monitoring all quality management activities, including new processes and services. The scope of work includes education, training, hands-on participation/leadership, and development of human resources in performance improvement for the whole organization.  It also includes collaboration with faculty and staff for all inpatient and outpatient departments in performance and quality improvement. This includes all the domains of quality, from patient safety, to practices consistent with current medical knowledge, and customization of care processes.  This position manages a staff of 12 FTE’s.

Reporting Relationship

Director of Quality Improvement/Patient Safety is responsible to and evaluated by the Chief Quality and Medical Information Officer.

Responsibilities

• Directs and leads the staff who work in all of the quality activities within the department, including Quality Managers and the technical staff of the Office of Outcomes Measurement.
• Participates as the administrative link between the Quality Improvement Patient Safety Committee and all of the centralized quality management activities.
• Maintains and administers a framework for continuously monitoring and improving the quality of care and service provided to patients
• Identifies, designs and implements new processes and services to continually improve patient care and services
• Provides leadership skills to accomplish Stanford Hospital and Clinic’s mission, goals and strategic plan.  Uses a systematic process to effectively plan, implement and evaluate policies, procedures, strategic plans and new programs.
• Effectively establishes and maintains collaborative working relationships with the medical staff to achieve increased physician satisfaction and participation with Stanford Hospital and Clinics (e.g., increased visits, patient days, and procedures).
• Integrates the measurement of clinical quality and service standards with those of strategic planning and operations management
• Identifies and improves the infrastructure supporting the services and staff who provide patient care
• Utilize and develop valid internal and external standards to measure quality
• Improves responsiveness and relations with all customers, including patients and their families, faculty and community physicians, other participating providers, affiliated health plans, staff, regulatory and accrediting bodies
• Provides leadership in the interpretation, implementation, and maintenance of standards to match external requirements (e.g., JCAHO, Title 22)
• Ensures the systematic collection of data regarding quality initiatives and the provision of forums for routinely reviewing this information with multi-disciplinary teams
• Provides forums to address cross-population/department/service quality management issues related to patient care, professional practice, education and research
• Engages physicians and Stanford Hospital and Clinics staff in quality management activities and encouraging accountability for quality at every level of the organization
• Provides education and training related to Quality Management activities, process and methodology to all staff.
• Manages departmental human resources, systems and workflow processes to achieve and maintain a budget neutral status.
• Communicates effectively to facilitate positive working relationships and achieve desired outcomes.
• Serves as a positive role model and effective liaison for Stanford Hospital and Clinics and its internal and external community.
• Annually identifies specific needs for self-development and implements a plan to achieve professional growth, networking and visibility.

Qualifications

• Masters Degree or equivalent in nursing, business, public health, or a related field and years of progressive hospital/nursing management experience, or an equivalent combination of education and experience required.
• Evidence of experience which defines competency in strategic planning, quality improvement, program evaluation, hospital administration and healthcare financial management.
• Evidence of experience in successful administration and leadership of organizational quality management programs.
• Knowledge of labor relations, economics and legislation affecting hospital administration and both medical and nursing practice.
• Expert knowledge of statistical analysis and reporting practices pertinent to quality improvement and program evaluation.
• Expert knowledge of common statistical programs, spreadsheet and database management, and word processing.
• Evidence of leadership, creativity, integrity, initiative and communication skills.
• Expert skill in presenting technical reports and leading large group discussions with medical clinicians and administrators. 
• Demonstrated history of successful publication in health care administrative, business, or quality management journals.
• Evidence of ability to promote and maintain good interpersonal relationships.

Personal Characteristics

The Director of Quality Improvement/Patient Safety, needs to possess the patience, self-confidence and communication skills necessary to work with the clinical and administrative staff and the Physicians.

First and foremost, this individual needs to be a team player, be a superb communicator and have the style of a diplomat, i.e., be able to work in harmony with other operational entities and to negotiate agreements so each party benefits. It is imperative that he/she be skilled in bringing together the staff functions in a spirit of harmony and with a single-minded purpose.

A hands-on leader who can develop a strategic vision of the department and has the expertise to develop values and goals for a diverse group of constituents will be successful.  The successful candidate will have a proven record of accomplishment of strong leadership skills to ensure that the improvement process within the department continues, that priorities are established and the goals are met.

The successful candidate will be a person who possesses a strong work ethic, rejects setbacks and values accomplishments highly.  An action-oriented personality that deals with specifics within a broad conceptual framework will be most effective in this position.  This individual will have an appropriate sense of urgency to react to situations quickly and decisively.

Compensation

The compensation plan is based on a competitive base salary commensurate with the experience and the demonstrated accomplishments of the successful candidate.  It will reflect the opportunity at the hospital. The hospital has an excellent employee benefits package, consisting of medical coverage, a dental plan, life insurance, Defined Benefit Retirement Plan and a 403 b program with employer matching.

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