System Director of Quality and Performance Improvement - Appalachian Regional Healthcare, Inc.

The System Director of Quality and Performance Improvement reports to the Vice President of Quality and
Clinical Excellence and will assist in the planning and execution of the organization's journey to high reliability
and a zero-harm culture to realize exceptional outcomes for our patients. This leader will help shape, then
execute, the quality assurance and performance improvement plan. They will support clinical departments and
hospitals across the system in evaluating outcomes to support improvements in objectives around
standardization and utilization.

She/He will perform a key leadership role in the development of an organization-wide culture of safety and
quality improvement, informing the evaluation and implementation of performance improvement (PI) models,
assessing PI education needs, linking PI activities and data with strategic goals. She/He will oversee the
database system management utilized to abstract, analyze and report national quality measure outcomes to
regulatory agencies and quality improvement benchmarking platforms.

Incorporates ARH’s vision, missions and values in goals and programs within Quality and Performance
Improvement.

Interprets impact of broad scope organizational change for staff and develops change strategies for successful
implementation.

Develops and manages operational initiatives with measurable outcomes.

Formulates objectives, goals and strategies collaboratively with other stakeholders.

Prepares and delivers reports to operational leadership outlining progress toward meeting annual goals and
objectives, to include performance related to clinical activity, quality, and safety.

Manage and direct all activities within area of responsibility.

Continually assesses all services, identifies problems, utilizes data to analyze and propose innovative approaches
for solutions.

Maintain records related to operations and services that are complete, accurate, available, and in compliance
with all legal, regulatory, and policy requirements.

Engages staff and other stakeholders in continuous improvement of systems and processes; manages resources
for staff participation in improvement work activities.

Ensures effective facilitation of improvement teams and development of leadership skills to ensure overall
effectiveness of the meetings.

Organizes and prioritizes time and resources to manage efficiency.

Remains current of new trends and best practices and incorporates into Quality - Patient Safety practices and
programs.

Articulates and enforces standards for quality and performance improvement in the delivery of exceptional
patient care.

Develops and implements innovative systems and processes that improve staff and patient quality and safety.

Demonstrates achievable and measurable results and develop action plans for improvement.

Initiates, monitors and enforces regulatory requirements.

Holds self and others accountable to policy, standards and commitments and provides timely follow through on
questions and concerns.

Ensures development of Quality and Performance Improvement initiatives to improve patient satisfaction and
family centered care.

Develops and implements clinical outcome measures for quality improvement, cost and complication reduction,
and the implementation of evidence-based practice.

Incorporates the use of evidence-based practice and appreciative enquiry into program development and
improvement activities.

Actively listens to staff ideas and concerns, assesses others communication styles and adapts to them.

Effectively facilitates Quality meetings at the system, local and organizational level.

Creates bi-directional systems that effectively communicate information and data, utilizing multiple methods.

Articulates and presents data, information and ideas in a clear and concise manner.

Communicates opinions and ideas in a non-threatening and nonjudgmental manner to staff, peers and others.

Communicates with physicians, department leaders, and senior administrators to maintain coordination with
other ARH programs.

Demonstrates empathy and concern while ensuring Quality goals are met.

Manages complex interdepartmental and interdisciplinary relationships to assure collaboration and
effective/efficient operations within Quality.

Creates an environment that encourages diverse opinions, recognizes differences and incorporates into process
and services.

Identifies lack of competency in others related to performance and establishes a plan which includes goals,
interventions and measures.

Maintains membership in professional organization(s) to develop knowledge and resources through networking,
continuing education, and participation in national, regional, and/or local activities.

Leads and/or serves on a variety of appropriate internal and external committees to represent Quality and

Performance Improvement at ARH.

Serves as a representative of Quality and Performance Improvement to ARH in order to facilitate the shared
interests and relationship between all parties.

Performs other duties as assigned

Complies with all policies and standards

Education (experience can be substituted for education)
Bachelors Degree in Nursing, other clinical-related field, or other healthcare profession Required.

Masters Degree in Nursing, Healthcare-related profession or Business Administration Preferred

Work Experience (education can be substituted for experience)
4-6 years Minimum of five (5) or more years of relevant experience in complex healthcare setting Required
7-9 years Seven (7+) or more years of relevant experience in complex health care setting Preferred
1-3 years Two (2+) or more years of manager (or higher) level experience in complex health care setting Preferred

Knowledge, Skills and Abilities
Excellent communication and interpersonal skills that include the ability to negotiate and resolve conflicts and build teams.
Demonstrated creativity and flexibility.
Ability to operate in high-pressure situations.
Excellent organizational skills.
Advanced working knowledge of Office 365 (e.g., ability to create custom pages, excel workbooks/worksheets and develop tools
using SharePoint’s advanced capabilities, cross-utilization of Microsoft Power BI, Tableau, etc.)
Demonstrated innovative approach to problem resolution.
Ability to work collaboratively across ARH entities and disciplines. Demonstrated commitment to patient- and family centered
care.
Broad knowledge of modern health care administration practices and principles within a healthcare environment in a rural
setting.
Effective analytical ability in order to develop and analyze options, recommend solutions to and solve complex problems and
issues.
Demonstrated effective managerial and administrative leadership of clinical.
Effective organizational, planning and project management abilities.
Experience in financial and programmatic presentations.
Ability to function independently and deal with multiple, simultaneous projects.
Ability to recognize personal strengths and weaknesses and develop goals for professional growth and achievement.
Ability to demonstrate a commitment to quality and excellence.
Effective leadership abilities:
Ability to implement change in a positive, sensitive and forward- thinking manner
Planning and problem solving
Developing goals and objectives, and establishing priorities
Inspires confidence, appropriate risk taking and achievement of high standards
Self-starter with a willingness to try new ideas
Positive, can-do attitude coupled with a sense of urgency
Good judgment and ability to act decisively at the right time
Ability to persuade others and develop consensus
Effective communication skills both in written and verbal presentation with a communication style that is open and foster trust,
credibility and understanding.
Ability to effect collaborative and promote teamwork
Ability to ensure a high level of customer satisfaction including employees, patients, visitors, referring physicians and external
stakeholders
Ability to create win/win solutions and relationships

Licenses and Certifications
Registered Nurse – Single State or Compact Preferred
Certified Professional in Healthcare Quality
(CPHQ) or other related professional
certification, Required or plan to obtain within
one (1) year. Required
Lean Six Sigma Certification, highly desirable Preferred
Project Management Professional certification
or equivalent, highly desirable Preferred