JOB SUMMARY: The Director of Quality & Patient Safety is responsible for leading and facilitating the quality operations of the entity in which they serve. This responsibility includes Infection Control, Accreditation/Regulatory Compliance, Patient Safety, Data Analytics and Reporting, and Quality Improvement. The Director supports hospital leadership in improving the patient experience and collaborates with the system level Program Directors to standardize processes across all operating units. Responsible for leading, managing, and coaching direct reports. Supports the VP-Quality in prioritizing system-wide quality initiatives. Leadership Functions Lead, manage, and coach quality team staff. Establish regular communications to entity and system level leadership and staff. Accreditation readiness. Patterns and trends identified from tracers, patient safety events and registry data. Findings from RCA including improvement plans. Departmental measure of success. Serve as entity point person for all on site surveys i.e. TJC, CMS, DCH, OSHA, etc. Communicate and/or update Leadership about changes in regulatory standards, quality improvement techniques, lessons learned from patient safety data (including RCAs and FMEA) and patient, provider and employee satisfaction results and improvement plans. Shepherd Quality Plan through the appropriate local committees for endorsement/approval. Collaborate with the system OoQ Corporate Director of Operations in all aspects of budgeting, purchases and payroll (time and attendance). Produce annual quality report. Patient Safety Responsible for internal and external reporting based on federal, state, and other regulatory requirements including sentinel events and notifying entity and system leadership of all reporting. Accountable for making improvement recommendations on all root cause analysis results to ensure consistencies with processes and policies. Oversee action plans are being monitored to ensure sustainability. Infection Prevention & Control Coordinate with system level IP to standardize processes in surveillance data collection, validation and reporting. Participate in developing the annual entity risk assessment. Collaborate with system IP to draft the Infection Prevention & Control Plan and shepherd through entity committees for approval. Active member of the system and entity Infection Prevention & Control Committee. Regulatory and Certification Maintain continued survey readiness. Collaborate with system coordinator and quality team to provide tracer training for staff and initiate scheduled tracer activities. Aggregate results from tracer and share with entity leadership and system coordinator. Serve as site coordinator for all on site surveys. Organize local team to develop responses to survey deficiencies and submit responses to the appropriate organization (TJC, CMS, DCH, OSHA, etc.). Quality Data Reporting and Analytics Oversee local data requirements. Timely collaboration with system staff on any validation data sent to external sources i.e. TJC, GHA, QHIP, CMS, NHSN, NSQIP and other registries if applicable. Timely internal reports to entity leadership and system leadership. Medical Staff Quality Functions Oversee medical staff mortality reviews and referrals for peer review. Assure FPPE/OPPE activities are current. Serve on Medical Staff Committees such as MEC, MPC and IPCC. Process Improvement Develop and implement process improvement plans within the entity and assure participation in coordinated efforts across the system. Lead efforts to implement High Reliability in processes and culture. Other duties as assigned.
MINIMUM QUALIFICATIONS: Masters degree from an accredited college or university in Nursing, Public Health, Healthcare Administration, Industrial and Systems Engineering, or other quality related field. (In lieu of a Masters degree, candidates with 10 years leadership experience in healthcare quality and accreditation may be considered). 7 years of experience in healthcare quality & accreditation. 3 years leadership experience. Must hold Six-Sigma and/or Lean certification and/or experience and attain CPHQ within 2 years of employment.