Position Description: System Director, Clinical Quality & Performance Improvement
St. Joseph Health System – Sonoma County, California (Part of St. Joseph Health System – Orange)

The Opportunity

This is a unique opportunity for a seasoned executive in quality and improvement management to significantly broaden and advance his/her career in well respected multiple-site healthcare system in Sonoma County, as well as being a part of one of the most  respected Health  Systems in the U.S.

Our Client

For nearly six decades our highly prestigious client, St. Joseph Health System, Sonoma County, has been Sonoma County’s premier healthcare provider.  St. Joseph Health System, Sonoma County is part of the highly prestigious St. Joseph Health System located in Orange, California.  St. Joseph Health System, Sonoma County is comprised of Santa Rosa Memorial Hospital, Petaluma Valley Hospital and St. Joseph Home Care Network of Northern California.

Santa Rosa Memorial Hospital has addressed the growing healthcare needs of the community by strategically adding state-of-the-art facilities and services throughout Sonoma County.  Santa Rosa Memorial Hospital, a 225-bed facility, is the county’s only level II trauma center.

Our Client also operates Petaluma Valley Hospital, a thriving 86-bed community hospital serving the south county.   St. Joseph Health System–Sonoma County also includes two urgent care centers.  The St. Joseph Health System also serves communities as far away as Lake, Mendocino, and Marin counties. The System has 2,800 employees. 

In addition to the acute care facilities, St. Joseph Health System, Sonoma County also operates one palliative care center and two hospices, Memorial Hospice and Hospice of Petaluma, and it provides mental health services throughout Sonoma County. There is a dental clinic in the southern county and the mobile medical and dental vans travel throughout Sonoma County and into Marin County to reach residents who can’t easily access health care.

St. Joseph Health System of Orange is a not-for-profit Catholic health care system. The System is comprised of fourteen successful hospitals, of which nine are located in California, three home health agencies and multiple physician groups.

St. Joseph Health System is an industry leader in providing quality care. All of its hospital and home health entities are accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and ten of these received scores of 90 or better and in many cases, with commendation.

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 clinical excellence, innovation and growth.  The style of management and the organizational culture of excellence are deeply rooted in teamwork and mutual support. 

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.

Reporting Relationship

Position reports the Chief Medical Officer.

Position Description

The Area Director of Clinical Quality & Performance Improvement is responsible for guiding, building and leading the hospital’s Clinical Quality and Performance Improvement (PI) program to support the Hospital's mission, values and business objectives. Key focuses for this position include:

• Building clinical programs that improve the quality and safety of the care provided by the St. Joseph Health System in Sonoma County.
• Maximizing performance and external awareness of St. Joseph Health System, Sonoma County by continuing to provide excellent service, as evidenced by the communities that it serves.
• Internal facilitation to achieve best practice. 

The position plans, organizes and directs all aspects of the Clinical Quality and Performance Improvement functions including clinical outcomes, patient safety, environment of care safety, infection control, risk management, operational improvements, service quality and organizational regulatory and accreditation readiness.  The Director in collaboration with other members of the department provides the organization with focus and education on performance improvement, outcomes reporting, and regulatory issues. 

Performance Improvement encompasses clinical outcomes, patient safety, environment of care safety, infection control, risk management, operational improvements, service quality and organizational regulatory and accreditation readiness

Responsibilities

• Creates an environment where:
• Best practices are accomplished through development of data driven strategies and tactics.
• Resources are identified, acquired, and freely shared across/among teams.
• Key stakeholders are engaged and accountable for achieving excellent outcomes.
• Helps position the St. Joseph Health System, Sonoma County as the premiere hospital system in Sonoma County relative to key clinical outcomes.  Examples of activities would include the development of clinical pathways with medical and hospital staffs, benchmarking, participation in multi-hospital collaboratives, and standardization of care to support Care Redesign and CPOE.
• Ensures integration of the Hospital’s quality, financial, operational and strategic planning processes to facilitate housewide focus and achievement of performance improvement priorities.
• Provides leadership in the interpretation, implementation, and maintenance of standards to match external requirements (e.g., JCAHO, Title 22) and maintains compliance with all legal, OSHA, HIPAA, State and Federal requirements. 
• Participates as the administrative link between the Quality Improvement Patient Safety Committee and all of the centralized quality management activities and maintains and administers a framework for continuously monitoring and improving the quality of care and service provided to patients.
• Champions an organizational environment of education, learning, and organizational comptencies at all levels using principles and tools for continuous assessment and achievement of Performance.
• Manages departmental human resources, systems and workflow processes to achieve and maintain a budget neutral status. 
• Develops a facilities planning and capital replacement program and periodically evaluates facility capabilities in order to meet the ongoing operational needs of the organization.
• 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.
• Ensures the systematic collection of data regarding quality initiatives and the provision of forums for routinely reviewing this information with multi-disciplinary teams.  Participates in the deployment of information technology initiatives.  
• Annually identifies specific needs for self-development and implements a plan to achieve professional growth, networking and visibility and builds the level of teamwork and support among the management.  Facilitates final conflict resolution and patient grievances as defined by the hospital’s Grievance Policy.

Qualifications

He/she will possess a Master or Doctor level degree in clinical field (e.g. MSN, Pharm.D, or equivalent level).  The successful candidate should have 5 - 10 years in Performance Improvement and 3-5 years of increasing responsibility in leadership/oversight of quality programs.  The incumbent will possess a License / Certification: National certification in performance improvement (e.g. Certified Professional in Healthcare Quality -CPHQ). 

Additionally the Area Director, Clinical Quality & Performance Improvement will possess:

• 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, spreadsheet, database management and word processing programs.
• 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. 
• Evidence of ability to promote and maintain good interpersonal relationships.

Personal Characteristics

The Area Director, Clinical Quality & Performance Improvement 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 and strong leadership skills to ensure that the improvement process within the department continues and 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 and a Bonus Program based on performance.  The Hospital has an excellent employee benefits package, consisting of medical coverage, a dental plan, life insurance, a vision plan and a Defined Benefit Retirement Plan with employer matching.

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