Director Quality SJMC-SCH

Virginia Mason Franciscan Health has a rich history of providing exceptional healthcare, dating back to 1891. Building upon a legacy of compassionate care and innovation, our organization has evolved over the years through strategic partnerships and integrations to expand our reach and services across the Puget Sound area.

Today, as Virginia Mason Franciscan Health, we remain deeply committed to healing the whole person – body, mind, and spirit – in the communities we serve. This commitment is strengthened by the diverse expertise and shared values brought together through our growth.

Our dedicated providers offer a full spectrum of health care services, from routine wellness to complex disease management, all grounded in rigorous research and education. Our comprehensive network of 10 hospitals and nearly 300 care sites strategically located across the greater Puget Sound region reflects our ongoing commitment to accessibility and comprehensive care.

We are proud of our pioneering medical advances and numerous awards and accreditations that reflect our dedication to excellence. When you join Virginia Mason Franciscan Health, you become part of a team that delivers top-quality, professional healthcare in modern, well-equipped facilities, and contributes to a legacy of service built on collaboration and shared purpose.

This position is responsible for the design, coordination, implementation and management of the Performance Improvement (PI) plan and identifies opportunities for improved patient care, incorporate evidence-based practices, and improved patient outcomes. Provides leadership in defining, implementing and integrating quality, safety, service and efficiency strategies into the plans, policies, and organizational processes that affect the organization’s operations and strategic direction.

Key Job Responsibilities:

Establishes performance improvement goals annually with relevant stakeholders, ensures that the PI plan and the hospital-focused projects for the year are implemented and effectiveness evaluated annually. Facilitates a multidisciplinary approach to performance improvement and fosters participation in all performance improvement initiatives to share and learn best practices. Develops and implements processes and formats that support data collection, aggregation, analysis, and action planning. Assures data is managed appropriately and disseminated to appropriate leadership staff.

Provides leadership in developing quality improvement training programs and coaches organizational clinical/service lines and operational/support departments in quality improvement principles.

Collaborates with the Medical Staff and Organizational Leadership to develop and enhance safe patient care while achieving optimal outcomes, including the organization’s peer review program and ongoing and focused practitioner evaluation.

Ensures compliance and provides leadership and oversight for accreditation, licensure and regulatory survey readiness. This includes mock survey tracers to assess survey readiness, education to staff and providers on regulatory compliance and identification for areas of opportunities and the corresponding actions for compliance at the facility level. Organizes
required staff to develop responses to survey deficiencies and oversees response submissions to the appropriate accreditation or regulatory agency.

Has overall accountability for assigned work group relative to operational goals, personnel requirements, and budgetary constraints.

Education and Experience Requirements:

• Bachelor's degree in a healthcare-related field or five (5) years of related job or industry experience in lieu of a degree. ∙
• Minimum of five (5) years of progressive management responsibility in a health care setting, two (2) of which is related to managing an acute care organization’s Quality Improvement Program.
• Minimum of two (2) years of clinical, patient care experience or equivalent.

Required Licensure and Certifications:

• Current State License in a clinical field.

• Five (5) years’ experience in Quality Management can be used in lieu of state license.

• Certified Professional in Healthcare Quality (CPHQ), or Healthcare Quality and Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment is required.