Provides leadership, development, and oversight of the site's Quality Management System and health outcomes for Aurora Medical Center Oshkosh and the new Fond du Lac site. This individual collaborates with operational leaders to ensure that the highest level of quality of patient care is delivered through data analysis, performance improvement activities and initiatives, the Quality Management System, and compliance with regulatory requirements and accreditation agencies. This position serves as a key role in facilitating key quality and regulatory communication to the site executive leadership team and medical staff.

Major Responsibilities:

• Directs, organizes, and plans the site clinical and administrative functions of the ISO9001 Quality Management System, including Quality Management Oversight Committee, and its requirements.
• Responsible for monitoring performance improvement activity in accordance with system and site safety and health outcomes priorities.
• Provides leadership and oversight to external agency visits, including accreditation and certification surveys, state surveys, and other agency investigations.
• Serves as the hospital management representative and preparation agent for DNV and ISO surveys
• Responsible for management and oversight of the hospital physician and APC peer review program including the provision of data and case review for OPPE and FPPE related processes.
• Oversees the hospital contract management program, including maintenance of a hospital log and overall evaluation.
• Responsible for the hospital document management program, including policies, procedures, scope of service, and other key site documents.
• Performs human resources responsibilities for staff which include interviewing and selection of new employees, promotions, staff development, performance evaluations, compensation changes, resolution of employee concerns, corrective actions, terminations, and overall employee morale.
• Develops and recommends operating and capital budgets and controls expenditures within approved budget objectives.
• Responsible for understanding and adhering to the organization's Code of Ethical Conduct and for ensuring that personal actions, and the actions of employees supervised, comply with the policies, regulations and laws applicable to the organization's business.

Licensure, Registration and/or Certification Required:

• None Required.

Education Required:

• Bachelor's degree in healthcare or related field.

Years of Experience:

• Typically requires 7 years' experience in quality improvement. Includes 3 years' experience in leadership role.

Knowledge, Skills & Abilities Required:

• Advanced knowledge of quality improvement methodologies (i.e. Lean, Six Sigma)
• Analytical and statistical skills
• Clinical knowledge of care processes
• Proficiency with MS Office
• Facilitation skills; excellent verbal and written communication skills
• Proficiency with change management
• Proficiency with project management

Physical Requirements and Working Conditions:

• Ability to sit for extended periods of time.
• Ability to travel to other AAH locations.
• Exposed to normal office environment.
• Operates all equipment necessary to perform the duties of the job.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.