Director of Quality Job Description

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POSITION: Director of Quality
DEPARTMENT: Nursing and Rehabilitation Services

As a member of the Leadership Team, the Director of Quality provides leadership, support, and guidance for comprehensive and effective planning, development, monitoring, implementation and evaluation of the services related to Quality and Risk Management, Patient Safety and Policy Management at the R.K. MacDonald Nursing Home. The Director of Quality works closely with the Director of Clinical Services to ensure clinical services are is aligned with best practice and excellence. Reporting to the CEO, the Director of Quality ensures the development and delivery of Quality/Risk/Safety activities, consistent with the Mission, Vision, and Strategic Directions of the R.K. MacDonald Nursing Home and establishes a culture that embraces the philosophy and approaches of continuous quality improvement.

The Director incorporates into daily practice the values of Compassion, Accountability, Respect, Excellence and Safety, coordination of R.K. MacDonald Nursing Home accreditation processes, survey and follow up, works in collaboration with the Director of Clinical Services to ensure the delivery of quality person centred care to residents and ensures policies and service delivery reflects best practice and evidence based care.

The Director of Quality serves as a positive role model; as a partner in the provision of care and support of our Residents, and represents the home in a positive, professional, efficient and confidential manner.

Key Responsibilities

1. Provides leadership and vision to the development and coordination of quality management initiatives aimed at improving overall quality of services, performance of the organization and its ability to achieve results with a particular focus on ensuring quality clinical services

  • Ensure adherence to clinical policies and best practice and works collaboratively with the Director of Clinical Services to ensure that polices are current and practical.
  • Develops quality indicators based on benchmarks and best practice in collaboration with Leadership team, Board of Directors Governance Committee , Accreditation Canada Specialist(s)
  • Chairs the Accreditation Committee and assumes accountability for the performance management of staff working within the Quality Management Program.
  • Ensure that all committees are structured and focused on meeting the Goals established by the Strategic Plan and Clinical Quality and performance plan.
  • Delivers satisfaction surveys to Residents and Families at least annually, works with respective departments to maintain or improve results and communicates results and improvement plan to all stakeholders
  • Delivers worklife pulse survey annually to staff analyzes and communicates results and works with Leaders and staff members to maintain or improve results.

2. Provides systematic monitoring and evaluation of quality initiatives throughout the organization and reports results to residents, families, Senior Leaders, Staff, Board of Directors and other stakeholders

  • Monitor quality program and initiatives, resident outcomes and works collaboratively with other Departments to maintain or improve results as required,
  • Works collaboratively with the Manager of Clinical Services to identify areas of improvement within the Clinical Services Directorate by using quality indicators

3. Promotes excellence in service delivery by researching, evaluating, and promoting activities that prove to be efficient, productive and cost-effective

  • Using Nursing expertise to review and update policies and best practices throughout the Nursing Department
  • Ensures that policies and procedures and current nursing practices within the facility reflect best practice, are current and reviewed and revised as necessary on an annual basis
  • Reviews current policies to ensure they are current and evidence based
  • Ensures current programs meet licensing requirements and are monitored for efficacy (Wound Care, Dementia Care etc)
  • Works closely with the Director of Clinical Services and the Education Coordinator to ensure new and updated information and skills are delivered in a timely manner

4. Ensures that effective Infection Control Program within the organization is carried out

  • Responsible for leading outbreak management in collaboration with Public Health Communicable Disease and Control staff
  • Delivery of resident immunization program, specifically Influenza Pneumovax and tetanus
  • Ensures the staff influenza immunization program is delivered annually (including rates of immunization)

5. Supports the maintenance of safe staffing levels, recruitment and retention of quality staff in collaboration with the Director of Clinical Services

  • Coaching, mentoring and empowering Charge Nurses, RN/LPN to work to the fullness of their scope of practice
  • Supports and assists the Charge Nurses coaching, mentoring and empowering clinical support staff regarding clinical services and alignment with core values

6. Accountable for the Safety and Risk Management

Uses data management and analytical skills for the consolidation of data relating to the monitoring, analysis, and reporting of quality and risk management initiatives, and system performance indicators.

  • Analyzes, trends and reports results from Safety Event reports
  • Chairs the Safety Event report team (SERT) and leads the work of the SERT to set and achieve goals that address safety issues throughout the organization
  • Works closely with JOHS to investigate staff injuries and mitigate future risk
  • Identification and management of potential risks in collaboration with Departmental managers, Charge nurses and other clinical support staff and assists in the plan to mitigate risk
  • Participates as a Leader in the JOHS program and Risk Management Program
  • Establishes a culture that embraces the philosophy and approaches of continuous quality improvement.

7. Provides leadership and support to initiate and lead the Quality Review Program by providing  a framework, including  supporting policy and procedure documents, guidelines, and tools to effectively promote, monitor, evaluate and improve the system of care for patients and ultimately patient safety.

  • Establish criteria and processes related to quality case review.
  • Assumes a leadership role in conducting quality case reviews
  • ensures that processes and structures are developed and maintained in such a way that promotes legislated “quality assurance privilege”

8. Communication: through personal behavior and interactions, will consistently demonstrates a humanistic, affiliative approach to relationships:

  • Within department, with other team members and with union representatives
  • In all interactions, within and while representing the facility
  • With all Residents and families
  • While establishing and maintaining cooperative working relationships

9. Ensures Continuous Quality Initiatives in all activities

  • Maintains clinical practice knowledge within professional designation and collaborates with Senior Leaders with other professional designations as required
  • Ensures professional license staff maintain practice knowledge
  • Ensures the implementation of evidence based/outcome management in the clinical services department
  • Determine patient care quality improvement goals and objectives in collaboration with the Director of Clinical Quality and Performance
  • Ensure that all staff maintain a current knowledge of trends and issues within the field and recommend changes in standards, policies and procedures, equipment and programs as appropriate
  • Analyze CQI data to identify solutions or improvements as required
  • Participates in Committees/teams as required
    • Ensure that all nursing committees are structured and focused on meeting the Goals established by the Strategic Plan and Clinical Quality and performance plan
    • Sits as a Chair of at least one organizational committee
  • Leadership Roles
    • Active participant on the leadership team
    • Demonstrates integration of the Mission, Vision and Values into practice
    • Participates in annual Strategic planning process
    • Participates in Succession planning
    • Evidenced based clinical decision making


Leadership Competencies Required 

  • Leading Others as demonstrated by the ability to establish focus, to provide motivational support, fostering teamwork, empowering others.
  • Managing Change as indicated by the ability to demonstrate support for innovation and for organizational changes needed to improve the organization’s effectiveness
  • Managing Performance as demonstrated by ability to take responsibility for one’s own or one’s employee’s performance by setting clear goals and expectations, tracking progress against goals, ensuring feedback and addressing performance issue promptly.
  • Communication as demonstrated by the ability to ensure that information is passed on to others who should be kept informed as well as the ability to express oneself clearly in conversations and interactions, in writing and to be able to plan and deliver conversations that have an impact and persuade their intended audience.
  • Interpersonal Awareness as demonstrated by the ability to notice, interpret and anticipate others concerns and feelings and to communicate this awareness empathetically to others
  • Influence Others as demonstrated by the ability to gain others’ support for ideas, proposals, objectives, projects and solutions
  • Building Collaborative relationships as demonstrated by the ability to develop, maintain and strengthen partnerships both internal and external to the facility
  • Customer Service Orientation perspective as demonstrated by the respectful, positive manner in which one responds to expressed concerns and the strong desire to find resolution and meet people’s needs
  • Information Gathering as demonstrated by the ability to identify information needed to clarify a situation and using skillful questioning to draw out information from reluctant sources
  • Thinking abilities including analytical, forward, conceptual and strategic abilities to enable one to tackle a problem, anticipate implications and consequences, find effective solutions and planning for the future direction of the Home
  • Initiative to identify what needs to be done and take action before being asked or the situation requires it
  • Results oriented to enable one to focus on the desired results, sets challenging goals and meeting or exceeding them
  • Thoroughness as demonstrated by ensuring that one’s own work, the work of employees and all information collected and shared is complete and accurate. Ensuring that commitments are fulfilled
  • Decisiveness as demonstrated by the ability to make difficult decisions in a timely manner
  • Self Confidence
  • Stress management
  • Personal Credibility
  • Flexibility

Position Specific Competencies

  • Clinical practice knowledge
  • Delivery models/designs knowledge
  • Safe practice initiatives
  • Utilization
  • Quality improvement Initiatives
  • Risk management theory & practice
  • Sound understanding of Ethical practice
  • Consistently acts as a role model for advocacy
  • Sound understanding of Union Contracts & Negotiations
  • Possess the person centered qualities and attitudes that respect the spirit, dignity and individuality of the Resident/resident and their family
  • Understands and is able to integrate a philosophy of person centered care into the daily operations of the nursing department
  • Able to supervise staff including the ability to mentor, coach and empower staff
  • A working knowledge of budgeting
  • Able to work independently and as part of the Leadership Team

Educational Qualifications

Baccalaureate Degree in Nursing or other Allied Healthcare Profession.  Masters Degree in preferred

Experience Required

5 years management experience in nursing
Experience in gerontology nursing an asset