The Program Director, Quality reflects the mission, vision, and values of Northwestern Medicine, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.The Program Director, Quality is responsible for the operational oversight, strategy and management of the specified service line functions system-wide. Responsible for planning and coordinating all or a portion of the overall operations of the Quality program for a specific operating unit at the direction of the assigned Director, Quality. Provides leadership, resources, tools, and analytics to improve quality outcomes in specified service line.  Coordinates and leads the quality endeavor, coordinates with peers, and is responsible for implementation and follow up as outlined in the annual quality plan, ongoing priorities of leadership and quality committees, and compliance with relevant standards monitored by The Joint Commission (TJC) and other agencies. This position will advance the use of quality evaluation and improvement strategies to achieve key organizational goals in quality and patient safety.  The Program Director partners with administrative, physician, nursing, and ancillary leadership to advance the quality agenda through the development and implementation of plans and strategies that facilitate the achievement of strategic organizational goals.Responsibilities:Plans, directs, and manages the overall quality operations of the service line program(s) for their business units. Collaborates with physician, nursing, and operational leadership. In collaboration with the team, the Program Director, Quality is responsible for the following:Perform annual risk assessmentsLead the development and implementation of the annual quality planActively prepare for and engage in relevant service-line-specific accreditation activities and surveysProvide quality support for payer center of excellence applications and processesImplement effective quality planningProvide leadership to department heads and clinical chairs in designing quality plans, programs and policies, peer review and adverse event review, and best practices within their departments.  Lead the department to identify quality opportunities and concerns, in collaboration with the Vice President of Quality, Director of Quality and relevant operational Director(s).Support/facilitate the implementation of systems and processes that promote a fair and just culture, and improve patient care.Facilitate discussion and achieve consensus with senior operational and physician leadership regarding key quality and patient safety metrics and prioritiesMay include collaborating to develop patient engagement strategies such as Patient Family Advisory CouncilRegulatory ComplianceAssure timely and accurate private and public reporting as requiredAssure compliance with service-line-specific Medicare Conditions of participation, Joint Commission standards, and other accreditation/licensure/ regulatory requirements (see: Competency/Performance expectations below)Oversee the creation, implementation, and tracking of effective corrective action plansProvide leadership and operational implementation of assigned Clinical Quality activitiesConduct detailed, sophisticated, accurate, timely, and comprehensive analyses of data at NMHC and outside NMHC (e.g. benchmarks, comparative data, CMS) to identify quality opportunitiesDevelop, conduct, and implement improvement activities to achieve high quality & high-reliability healthcare. Identify and utilize appropriate quality metrics to evaluate project or performance success based on stated purpose and needed outcomes.   Advance performance compared to appropriate external benchmarks and optimize process and outcome metrics.In collaboration with clinical operations, implement best practices which will improve quality outcomes within the organizationServe as organization expert on best practices, national and local trends and issuesCoordinate organizational responses to regulatory standards related to quality such as Joint Commission, CMS, IDPH, and specialty-specific programs.Provide oversight for relevant CMS and other agency data submission and ensure compliance with data requirements (e.g. validation, etc.)Lead communication, teaching, modeling, process consultation and implementation of best quality practicesSupport NM quality programShare quality activities across NMHC and coordinate collaborative NMHC quality efforts as assigned.Maintain a current understanding of quality theory, measures, methods, standards and regulatory requirements.Participate in the development, review, and revision of policies and procedures that affect quality.Maintain collaborative relationships with other departments including, but not limited to, Accreditation and Compliance, Risk Management, Patient Safety, Process Improvement, Clinical Documentation, and Nursing, Medical Staff, Pharmacy, Contracting and Payor Relations, and other disciplines.Continuously evaluate and improve the quality program based on internal needs and external requirements and standards. Support effective department operations and growth, and personal developmentBuild strong interdisciplinary partnerships  Provide support to Nursing, Medical Staff, Laboratory, and all clinical areasSupport, coach, teach, mentor, monitor and evaluate the work of others conducting quality work (as directed) and personally conduct, coordinate, facilitate, and participate in quality assessments, improvement efforts, committees, etc.Recruit, manage, mentor, coach, and develop staff as assigned, to optimal professional effectiveness and engagement.Oversee effective use of budget and other resources as delegated.  Supervise 1-2 staff.  Supervise projects with organizational impact, and manage intermittent staff assignments.Responsible for self-development and professional engagement, including knowledge of the literature and attendance at professional meetings, preparation of manuscripts, posters and presentations, involvement with local and national task forces as relevant
