Director, Chief Nurse Quality

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POST DATE 8/30/2016
END DATE 10/21/2016

Christus Health Irving, TX

Irving, TX
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Mid-Career (2 - 15 years)
Bachelors Degree



The Director of Quality and Chief Nurse for CHRISTUS Physician Group (CPG) is responsible for the clinical practice of nursing, and the strategic planning and oversight of clinical quality, patient safety, clinical risk management, pay for performance and clinical practice in the non-acute ambulatory care settings. The director works with the Medical and Operational leaders of medical practices, urgent care sites and other care delivery systems as developed across a large geographical footprint. This role creates alignment between the ambulatory and acute care settings and is responsible for progressing a seamless continuum of care for patients, families, and communities.

Ambulatory responsibilities include, but are not limited to oversight of: clinical and nursing practice(s), facilitation of Quality, Risk, Safety, Compliance and Credentialing (QRSCC) Committees for the physician and urgent care practices, driving integration of EHR documentation to support evidence based clinical practice, clinical data mining and analysis, clinical data reporting, clinical process improvement and the management of clinical variance reporting. This work requires collaboration across multiple disciplines and teams at the corporate office including Nursing, Quality, Risk, Privacy, Legal, Information Management and Health Infomatics.


* Ensure compliance with State Board of Nursing Rules and Regulations, and other regulatory bodies governing the delivery of care by licensed and non-licensed ambulatory healthcare team members
* Facilitate committees responsible for oversight of Quality, Risk, Safety, Compliance and Credentialing (QRSCCs) in medical and urgent care practices with the corporate and regional medical leaders
* Strategically plan and execute annual Quality and Safety Plan(s) for areas of responsibility that aligns with CHRISTUS Health System strategic goals and initiatives
* Develop, track, analyze and manage clinical information and data for the local, regional, and system level use and reporting to monitor and drive improvements in clinical quality and patient safety
* Design and build a structure and team members that support the delivery of the best possible evidence based care at practice sites
* Coordinate across teams to educate clinicians on evidence based practice and clinical documentation
* Utilizes a CPG-wide communication strategy to keep clinical teams informed of important clinical updates
* Utilizes a variety of quality improvement tools, such as Six Sigma, CQI, and Lean processes, to drive results
* Ensure successful reporting for pay for performance programs

Patient Safety
* Establishes a culture of safety across the organization through active support of a \\"Just Culture\\"
* Manages variance reporting and implements HFACS methodology to investigate clinical variances and/or near misses that have potential to result in negative patient outcomes.
* Executes the annual quality and patient safety plans driving the initiatives selected by the QRSCC Committees and those identified through variance reporting
* Implements in collaboration with the EMR team patient safety principles and practices into the design and maintenance of clinical information systems as appropriate.
* Participates on the System Patient Safety Council and acts as internal consultant to system, regional and local leaders in matters of clinical quality and patient safety.

Chief Nurse
* Maintains knowledge of Nursing Scope of Practice in States with CPG practice sites
* Oversees nursing practice and clinical activities of medical assistants
* Mentor and develops nursing leaders to support the delivery of care in regions
* Provide oversight and management of the DCO Worksite Clinic.
* Participate in system nursing leadership counsels and activities
* Participate in professional development activities and maintain professional affiliations.
* Uses oral and written communication skills to effectively convey ideas in a clear, positive manner that is consistent with the CHRISTUS Mission.
* Performs other related work as required.


Physical Demands:
The physical demands described here are representative of those that must be met by an Associate to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
o While performing the duties of this job, the Associate is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; taste or smell. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

Work Environment:
Work environment characteristics described here are representative of those that must be met by an Associate to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
o While performing the duties of this job, the Associate is not exposed to weather conditions.
o The noise level in the work environment is usually moderate.



A. Education/Skills:
* RN licensure with Bachelor's Degree required and Master's Degree preferred
* Experience in managing clinical and operational needs in a non-acute care setting.
* Ability to motivate and manage as a transformational leader
* Strong research and writing skills
* Strong communication and presentation skills
* Knowledgeable of clinical information systems
* Experience analyzing and reporting data
* Knowledgeable of current trends in managing patients across the care continuum
* Knowledgeable of Pay for Performance Programs such as Meaningful Use, ACOs,

B. Experience
* Seven (7) to ten (10) years of experience in a health care setting, preferably with medical practice experiences
* Knowledgeable of evidenced based care delivery.
* Understanding and previous involvement with National/Regional Quality Improvement Organizations and/or initiative.
* Experience working with all levels of staff to drive adoption of best practices
* Experience working with medical and administrative leaders
* Experience developing and leading local and remote teams through innovative uses of technology
* Expertise in driving sustainable results through a variety of process improvement methodologies

C. Licenses, Registrations, or Certifications:
* Certified Professional in Health Care Quality (CPHQ) Certification - preferred