Director - Quality and Performance Improvement (1.0 FTE, Days)

This job posting is no longer active

Category: Process Excellence
Job Type: Full-Time
Shift: Days
Req: 14932
FTE: 1

Process Excellence

1.0 FTE, 8 Hour Day Shift

At Stanford Children’s Health, we know world-renowned care begins with world-class caring. That's why we combine advanced technologies and breakthrough discoveries with family-centered care. It's why we provide our caregivers with continuing education and state-of-the-art facilities, like the newly remodeled Lucile Packard Children's Hospital Stanford. And it's why we need caring, committed people on our team - like you. Join us on our mission to heal humanity, one child and family at a time.

Job Summary

This paragraph summarizes the general nature, level and purpose of the job.

Working in partnership with hospital administrative and medical staff leadership, the Director provides leadership, strategic direction and oversight for the development and implementation of a comprehensive continuous improvement function that systematically measures, prioritizes, supports, and monitors improvement programs and activities that will result in high impact, significant outcomes for patients, staff and the organization. This role will contribute to the Lean transformation of the organization by overseeing and leading large, complex enterprise-wide strategic and operational efforts to enhance quality of patient care, promote a culture of safety and improve effectiveness and efficiency at Lucile Packard Children's Hospital Stanford. This position leads and drives performance of the quality and performance improvement sub-functions, which includes the Quality Improvement and Performance Improvement teams. The leadership and staff of both teams work collaboratively with various stakeholders throughout the enterprise to deliver value to patients and families.

Other responsibilities include budget management; developing and maintaining strong collaborative relationships with organization-wide divisions and members of the medical staff to ensure open communication and the sharing of information; ensuring that the Quality Assurance and Performance Improvement (QAPI) structure within the organization adheres to standards set forth by various accreditation and regulatory agencies (CMS, Title 22, etc.).

 Essential Functions

The essential functions listed are typical examples of work performed by positions in this job classification.  They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities.  Employees may also perform other duties as assigned.

Employees must abide by all Joint Commission Requirements including but not limited to sensitivity to cultural diversity, patient care, patient rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings.

Must perform all duties and responsibilities in accordance with the hospital’s policies and procedures, including its Service Standards and its Code of Conduct.

  •  Serves as a key leader in advancing the Lean based Packard Quality Management System (PQMS) and ensures alignment of transformational efforts to the organizational True North.
  •  Develops and implements a comprehensive continuous improvement function that systematically measures, prioritizes, supports, and monitors improvement programs and activities aimed at improving the quality, safety, efficiency, and cost-effectiveness of patient care.
  •  Develops and implements a framework for continuously monitoring and improving the quality of care and service to patients and promoting a culture of safety.
  •  Develops and oversees short- and long-range goals and requirements pertaining to organizational performance in quality and performance improvement for incorporation into strategic planning.
  •  Influences executive, senior, and front-line leaders in their problem solving, planning, thinking, and decision making that aligns with organizational True North and strengthens PQMS across the enterprise.
  •  In collaboration with various stakeholders, develops the institutions annual quality improvement and patient safety plan, and evaluates progress toward the plan.
  •  In conjunction with the medical staff and hospital leadership, develops and oversees a comprehensive performance improvement program inclusive of the analysis and trending of data related to initiatives.
  •  Provides support in identifying, designing, and implementing new processes and clinical care, based on evidence, to continually improve patient care and outcomes and to achieve performance targets.
  •  Provides leadership, strategic direction and high-level management to Quality and Performance Improvement staff, assigning work streams and activities based on expertise, development opportunities and workload.
  •  Ensures the development of team members (QI/PI staff and work teams) through coaching, A3 thinking and the provision of experiential learning.
  •  Fosters and maintains collaborative relationships within the hospital and clinics, the School of Medicine, medical and patient care staffs, and with external agencies and stakeholders related to quality, safety and performance improvement initiatives.
  •  Serve as Associate Director, Operations, on the Executive Committee for the Stanford Medicine Center for Improvement (SMCI).
  •  In collaboration with clinical staff and services chiefs, participates in the monitoring, reporting, and execution of improvement activities related to clinical guidelines, health care quality/safety initiatives, accreditation and regulatory requirements.
  •  Provides leadership for development of Quality Assurance and Performance Improvement (QAPI) structures within LPCHS in conjunction with Medical Staff and Nursing leadership.
  •  Manages budgets effectively and determines fiscal requirements and prepares budgetary recommendations.
  •  Oversees management of departmental human resources, systems and workflow processes to achieve department goals and objectives; provides direct supervision to the leaders of the Quality and Performance Improvement teams supporting improvement efforts at Stanford Children's Health.
  •   Oversees the systematic collection, reporting, analysis and interpretation of data regarding quality and safety initiatives and the provision of forums for routine review of this information with multi-disciplinary teams.
  •   Proactively educates leadership and staff regarding Quality, Safety and Performance Improvement issues, guidelines, methodologies, and improvement activities.
  •   Provides forums to address cross-population, department, service quality management and safety issues related to patient care, professional practice, education and research and engages physicians and hospital and clinic staffs in quality and safety improvement activities, encouraging accountability for quality at every level of the organization.
  •   Provides strategic oversight for the Quality and Safety Oversight Committee with accountability for distribution of organizational communication vertically and horizontally, as appropriate.
  •  Provides overall direction necessary to ensure that clinical services are provided in accordance with standards established through state and federal regulations and Joint Commission accreditation standards, including the National Patient Safety Goals, and that are evidence-based. Identifies areas of vulnerability and directs the development of strategies to enhance compliance.
  •  Ensures the effective management of enterprise improvement initiatives in collaboration with sponsors / SCH Executive and the Quality and Performance Improvement leadership teams.
  •  Serves as the Survey Operations Center co-leader during all large scale regulatory and accreditation visits.
  •  Engages in Department level rounding on staff and stakeholders to understand front line quality and performance improvement issues and opportunities for support.
  •  Provides education in the area of quality improvement to departments, providers, and the community and assists in ensuring compliance with regulatory and accrediting organizations.
  •  Advises and supports executives and other senior management engaged in leading transformation initiatives throughout the enterprise.
  •  Serves as internal consultant and attends meetings, including but not limited to the Quality & Safety Oversight Committee, Patient Safety Committee, Infection Control Committee, HAC Leadership etc.
  •  Serve as internal improvement consultant and represents Quality and Performance improvement at strategic committees as identified in collaboration with cpmV senior leadership.
  •  Participates in a national network of quality and performance improvement professionals, sharing best practices, tools and materials while participating in ongoing communication activities and capacity-building peer exchanges.
  •  Keeps abreast on quality improvement practices, making the quality department aware of them and suggesting areas where they could be implemented.
  •  Ensures continuous improvement of PQMS by monitoring external environment (e.g., trends in improvement science and healthcare)  and incorporating new thinking for continuous improvement.
  •  Monitors the impact and value of transformational and key improvement activities, and identifies continuous improvement opportunities.
  •  Encourages the de-selection of improvement initiatives that do not align with our True North or PQMS mindset and/or increases the work-load beyond a manageable level.
  •  Demonstrates problem solving, leadership, conflict management, and team building skills in order to ensure a productive work environment and achievement of goals.

 Minimum Qualifications

 Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying.

 Education: Master's degree in a work-related discipline/field from an accredited college or university. MPH, MHA, MS or MSN preferred.

 Experience: Broad, extensive and progressively responsible work experience in this specialty area.  Seven (7) years of directly related work experience, as an advanced lean practitioner and quality improver.

 License/Certification: None required.


 Knowledge, Skills, & Abilities

These are the observable and measurable attributes and skills required to perform successfully the essential functions of the job and are generally demonstrated through qualifying experience, education, or licensure/certification.

  •   Ability to communicate effectively at all organizational levels, both orally and in writing, and to instruct, persuade, resolve conflicts, & consult.
  •   Ability to make effective oral presentations and prepare concise written reports to a variety of audiences.
  •   Ability to plan, organize, prioritize, work independently and meet deadlines.
  •   Ability to provide leadership and influence others at all levels of the organization.
  •    Exemplary coaching skills, developing leaders through asking questions and humble enquiry.
  •    Able to establish and maintain effective relationships with widely diverse groups, including individuals at all levels both within and outside the organization.
  •    Ability to resolve conflicts and negotiate with others to achieve breakthrough results.
  •    Ability to motivate, engage and sustain team members in the improvement journey.
  •    Knowledge of computer systems and software used in functional area.
  •    Knowledge of principles and practices of strategic planning, quality improvement, program evaluation, hospital administration, healthcare financial management, inpatient and clinic operations, and primary support processes.
  •    Knowledge of statistical analysis and reporting practices pertaining to quality improvement and program evaluation.
  •    Advanced understanding of lean principles, systems, methods & tools. Able to act as both a thought leader and operational expert in lean management systems, methods & tools.
  •    Exemplary project management skills with the ability to ensure that key milestones and deliverables are achieved as agreed.
  •    High level assessment and evaluation skills that focus on the elements of value as they relate to our patients, staff and the organization.
  •    High level strategic thinking, conceptual and analytical skills.
  •    Highly developed collaboration and partnership skills, working with others to deliver a shared vision and continuous improvement in performance. 
  •    Adaptable and flexible with an ability to learn rapidly, pivot when necessary in response to a dynamic environment.
  •    Deep understanding of A3 thinking and the importance of Gemba based learning and PDCA.


 Physical Requirements

The Physical Requirements and Working Conditions in which the job is typically performed are available from the Occupational Health Department. Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions of the job

Stanford Children's Health is committed to the deployment of a management system based on Lean Thinking, where the goal is to deliver value by continuously improving the quality and service of the care we deliver while also increasing affordability of care through the removal of waste. This is done by empowering, developing, and supporting leadership and front-line workers to improve processes and solve problems as part of their daily work. At Stanford Children's Health, our improvement approach is called the Packard Quality Management System (PQMS). PQMS is a patient and family-centered management and improvement system for making our work simpler, more effective and safer so that we can make every patient's and family's outcomes and experience extraordinary. The Performance Improvement department, reporting up to the Chief Quality Officer, is leading the development, promotion, & deployment of PQMS.

Equal Opportunity Employer

Lucile Packard Children’s Hospital Stanford strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, LPCH does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements, and where applicable, in compliance with the San Francisco Fair Chance Ordinance.