Reporting to the Chief Medical Officer, responsible for the oversight, leadership and direction of the healthcare quality and patient safety programs for Mount Auburn Hospital and Mount Auburn Professional Services' (MAPS) ambulatory practices. Serves as an organizational leader in design, development, implementation and monitoring of quality and safety initiatives, plans, metrics and goals. Leads change by using continuous performance improvement methods to support ongoing regulatory readiness, improved quality outcomes, reducing preventable harm and improving patient and caregiver experience.

The Director of Quality & Patient Safety acts as an expert resource across the organization overseeing complex projects to completion through team facilitation and team building. This role collaborates with leaders and staff, and is a role model and in high reliability, just culture, change management theory, and regulatory standards. Interacts with the Board of Trustees to support committee meetings.

The Director actively leads interventions that reinforce and support a culture of safety and high reliability. This role collaborates with leaders across the organization Root Cause Analysis (RCA), Failure Mode Effects Analysis (FMEA) and other quality and safety tools that support a journey to achieving zero patient harm.

Responsible for data submission to clinical indicator and quality measurement systems and internal and external benchmark databases. Manages direct reports (quality data analysts, Quality and Safety Nurse Specialists and patient relations specialists)

Job Description:

Essential Duties & Responsibilities (including but not limited to):

1. Initiates, oversees, and integrates a comprehensive clinical patient safety program as a component of the hospitals' quality services to improve safety of patients, visitors and employees

• a. Collaborates with senior leadership, management and physician colleagues to achieve quality outcomes and programmatic goals
• b. Collaborating closely with the Director of Regulatory Affairs and Performance Improvement, develops the annual PI Plan, Work Plan and goals.

2. Acts as key resource in Quality and Safety leadership, and works closely with clinical, medical and administrative leadership to promote system wide applications of patient safety, and quality improvement strategies

• a. Identifies root causes of adverse occurrences, reports activities to leadership, and facilitates action plan development to resolve and learnings from occurrences

3. Coordinates the organization's safety event reporting program.

• a. Educates staff about reporting responsibilities.
• b. Manage online reporting system, and provides for communication and education for managers and senior leaders.
• c. Oversees the investigation of all sentinel events with the appropriate groups.
• d. Maintains a leadership role in development an institutional culture of patient safety and non-punitive reporting of adverse events.
• e. Coordinates learning and data analysis identified through the incident reporting system.
• f. Oversees the Peer Review process including preparation of case summaries/questions, and supports communication of findings to the Medical Staff Office

4. Provides leadership to individuals and interdisciplinary teams assure oversight of process and outcome measures, and collaborates with the Director of Regulatory Affairs and Performance Improvement on the reporting of clinical quality measures to Joint Commission, CMS and MassHealth to meet regulatory requirements.

• a. Manages internal Analysts and/or Quality data abstractors to meet all required data reporting, audit and validation requirements.
• b. Deliver presentations on Quality reporting requirements and hospital outcomes as required.
• c. Works with the performance measures team to assure compliance with Hospital's required data registry reporting
• d. Works with the performance measurement team to evaluate and manage outside data abstraction services
• e. Develop and maintain tools and project plans to manage accuracy and integrity of data for external and system reporting systems of clinical quality data.

5. Coordinates and oversees data collection and analysis, public reporting, measure validation processes, pay for performance initiatives, annual Leapfrog survey, US News and others.

• a. Performance measure data reported to the system including system Quality Goals
• b. Performance measure data from external agencies (CMS, MassHealth, Leapfrog, Joint Commission)
• c. Patient Experience data (Press Ganey)
• d. Commercial Payer Pay-for-Performance programs (BCBS AQC, HPIP, HPHC)
• e. Comparative Performance data from benchmarking systems (Vizient, MIDAS)
• f. Reports and metrics from the EHR (Epic) and other Clinical Systems
• g. Provide clear, concise, narrative summaries of performance for clinicians and administrators.

6. Collaborates with the Director of Performance Improvement and Regulatory Affairs to co-lead external agency surveys, e.g. TJC, DPH, CMS

7. Acts as a liaison with the Massachusetts Coalition for Prevention of Medical Errors, Institute for Healthcare Improvement and the Institute for Safe Medication Practices.

• a. Keeps current with emerging initiatives
• b. Includes emerging national or local initiatives into ongoing recommendations for improvement initiatives.
• c. Plans designs, and implements educational programs for staff to maintain compliance with standards.

8. Responsible for the management and supervision of the Quality Data Analysts, Patient Relations Specialists and QS RN specialists

• a. Develops and implements processes for the selection, evaluation, promotion of staff within the department/division. Acts as mentor

9. Assumes accountability for determining, developing and evaluating annual budget.

10. May perform other job related duties as requested or required

Minimum Qualifications:

1. Bachelor of Science in Nursing or equivalent clinical experience required.

2. Master's degree in Nursing, Health Care related field, or Hospital Administration preferred.

3. Minimum 5 years supervisory or management experience required.

4. Must possess a working knowledge of healthcare quality and patient safety management, data sets and databases, benchmarking, outcome measurement, team development.

5. Certification preferred in CPHQ, CPPS or other nationally recognized quality and/or safety certification program.

6. Experience in statistical analysis and current quality improvement tools/methods. Facility in using Microsoft Excel required

7. Current knowledge of CMS, DPH and MassHealth hospital quality reporting requirements

8. Experience with database, spreadsheets and statistical process control charts.

9. Ability to demonstrate sound critical thinking/decision-making and ability to function well under pressure. Strong analytical ability and statistical knowledge.

10. Strong interpersonal, oral and written communication skills.

11. Proficiency with Microsoft Office including PowerPoint, Project and SharePoint required.

12. rL6 Safety Reporting and Epic EHR and project management tools preferred

An equivalent combination of education and experience, which provides proficiency in the areas of responsibility listed above, may be substituted for the above education and experience requirements

Physical Requirements & Environment:

1. Normal office environment.

2. Requires periods of heavy keyboard work.

Pay Range:
$130,000.00 USD - $159,994.00 USD

The pay range listed for this position is the annual base salary range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law.