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1 POSITION SPECIFICATIONS Title: Organization: Location: Website: Director of Quality Mercy Hospital Ardmore Ardmore, Oklahoma ORGANIZATION Mercy Hospital Ardmore is the primary healthcare provider for Ardmore, Oklahoma, and much of southern Oklahoma. This 190-bed full-service tertiary hospital has nearly 1,100 employees and 150 physicians on staff. The Hospital was formerly known as Memorial Hospital of Southern Oklahoma and became part of the Sisters of Mercy Health System in August The Hospital operates under the sponsorship of the St. Louis-based Mercy Health System, one of the largest Catholic healthcare systems in the country. The original hospital building was built by the Southern Oklahoma Memorial Foundation in However, the Hospital opened a $63 million expansion project in June The project includes a new patient tower with 158 private patient rooms, a new Intensive Care Unit, a women's health center and a new main entrance to the hospital. The city of Ardmore has a population of nearly 25,000. However, the estimated trade area for Ardmore represents more than 135,000 people. Ardmore has the advantages of a small town, while also enjoying the benefits of being near two large metroplexes. With I-35 running through the city connecting Dallas and Oklahoma City, Ardmore is always growing. Dallas and Oklahoma City are nearly equidistant, approximately 90 miles, from Ardmore. Ardmore is a great place for families because the city has a low cost of living, top ranking public schools, a private school, youth camps and options for higher education. The area is known for its beauty, including Lake Murray, the Arbuckle Mountains, Turner Falls, and Chickasaw National Park. Other area attractions include a historic downtown and train station, horse and livestock shows, a Golf Digest Top 100 Best Golf Courses in the United States and WinStar World Casino, the 5 th largest casino in the world. In addition, Ardmore is home to the Samuel Roberts Noble Foundation, an independent, non-profit institute conducting plant science research and agricultural programs to enhance agricultural productivity. For more information on Ardmore, please visit

2 Mission Statement As the Sisters of Mercy before us, we bring to life the healing ministry of Jesus through our compassionate care and exceptional service. The mission statement of Mercy is an inspiring reminder of our calling. It also unites and directs activities across our entire health and human services ministry. Vision We are the people of Mercy Health Ministry. Together, we are pioneering a new model of care. We will relentlessly pursue our goal to get healthcare right. Everywhere and every way that Mercy serves, we will deliver a transformative health experience. 2

3 REPORTING RELATIONSHIPS The Director of Quality: Reports to: Supervises: Relates to: Vice President of Medical Affairs Quality Management Staff (4 individuals) Regulatory Compliance Patient Relations Infection Control Chief Executive Officer Vice President of Patient Care/Chief Nursing Officer Vice President Finance Mercy Health System leadership Regulatory officials Vendors GENERAL INFORMATION The Director of Quality serves as a critical leader of the hospital, overseeing all quality management services at Mercy Hospital Ardmore (MHA). The position reports to the Vice President of Medical Affairs but also maintains a very close working relationship with the Chief Executive Officer and the Vice President of Patient Care. The Director serves as a member of the Hospital Leadership Team. The Director of Quality provides direction for four specific areas: Quality Management: This Director is responsible for Core Measures, VBP, Medical Staff Peer Review, Contracted Services, QIO follow-ups, Root Cause Analysis, NDNQI, Nursing Dashboard, Culture of Safety, Board/Committee Reports. Regulatory Compliance: This office is responsible for EOC Safety, Emergency Management, Life Safety Oversight, Six Sigma, Joint Commission, Oklahoma State Health Department Survey. Patient Relations: This office is responsible for Patient Satisfaction, Call back, Service Recovery, Service Excellence Committee, PRC. Infection Control: Prevention Control, Surveillance, Monitoring, State HAI Reports 4

4 The Director of Quality will serve as a visible and active leader on the MHA leadership team. In addition, he/she will provide confident leadership to the physicians, nurses and hospital leadership who manage the care of patients in the hospital. GOALS & EXPECTATIONS During the first year, the Director of Quality will need to establish credibility as an operationally and clinically astute leader who can lead staff in all areas of Quality at MHA. Specific goals that have been identified as measures of success for the first 18 to 24 months include: Build trust with hospital Leadership and physicians that establishes the Director as the Quality expert in the Hospital; Develop the relationships necessary to be viewed as a valued Quality leader at MHA and Mercy; Develop a strategic direction for the Quality Department that integrates current initiatives with new requirements of ACA and TJC; Improve all Core Measure scores so that they are at the 95th percentile and moving toward 100 percent; Generate clinical data that will support clinical analysis, decisions and clinical quality; Complete the accreditation process for TJC (last survey was May 2012); Improve co-worker engagement scores; Improve hospital HCAHPS and VBP satisfaction scores to meet current financial goals; Help department directors create quality improvement projects using LEAN or Six Sigma concepts for key departments and hospital initiatives; Continue to develop the Quality Department staff and create a team of independent experts; 5

5 CANDIDATE PROFILE The following describes many of the characteristics of the ideal candidate for the Director of Quality at MHA. Education Well-prepared academically, bachelor degree required; masters prepared candidates are preferred; Strong preference for a registered nurse with eligibility for Oklahoma licensure; candidates without a nursing degree/licensure with extraordinary experience in quality and assessment service management may also be considered; Appropriate professional certifications (such as CPHQ) is preferred; Experience/Skills A strong background in Quality and core measures leadership with at least three years of progressive leadership experience and demonstrated results in employee, physician, patient and customer relations; A demonstrated ability to build effective teams and to lead, mentor and develop a department; experience in process improvement is important; A track record of commitment to patient care, sensitivity to clinical issues along with a grasp of quality management and strong grounding in every aspect of patient care, including budgeting; A strong customer service orientation and a track record of measurably improving customer service; A management style which is fair, consistent, open, and inclusive, but emphasizes accountability and measures results; an advocate for both patient care and nursing; Successful experience managing the financial aspects of leadership (budgets, margins, productivity, etc.); A track record of strong physician relationship-building; Personal Characteristics Strong, demonstrated relationship skills that foster trust and teamwork and a common 6

6 focus on excellence in all areas; A team player and team builder who focuses on the good of the entire organization and can inspire others to work together to achieve organizational excellence; A good communicator who is also a good listener and can be comfortable and effective at all levels of the organization; strong written and verbal communication skills are also important; candor and common sense is appreciated; A creative, pragmatic problem solver who is energized by challenges and change and identifies untapped opportunities to capitalize on within the organization; A demonstrated high level of integrity; guided by a sound set of ethical principles; Energy and enthusiasm, yet able to exude a calming influence when needed; eventempered and able to exhort a spirit of dignity and optimism; a good sense of humor; A leadership style which emphasizes empowerment and visibility within the facility; Must be compatible with and passionate about MHA s faith-based mission of service and ministry; For more information, please contact: Joe Pettigrew, Ph.D. Affiliate Partner FaithSearch Partners, Inc jpettigrew@faithsearchpartners.com or Ivan Bartolome Senior Vice President FaithSearch Partners ivan@faithsearchpartners.com 7