Job SummaryThe Director of Quality and Patient Safety is responsible for leading and overseeing the hospital's quality management program, ensuring the delivery of safe, effective, and patient-centered care. This leadership role includes developing and implementing strategies to drive continuous improvement, maintain accreditation standards, and promote a culture of excellence.
Essential Job Responsibilities- Promote the mission, vision, and values of the organization
Quality Management & Improvement:- Lead the design, implementation, and monitoring of hospital-wide quality initiatives aligned with national, state, and local standards.
- Develop and oversee quality improvement programs that focus on reducing clinical errors, improving patient outcomes, and ensuring compliance with accreditation standards (e.g., CIHQ, CMS, etc.).
- Monitor, collect, analyze, and report core measures, electronic clinical quality measures (eCQMs), Meaningful Use metrics, and Inpatient/Outpatient Quality Reporting (IQR/OQR) measures in compliance with regulatory and organizational requirements.
- Participates in Clinic quality improvement initiatives (e.g., MACRA, MIPS, ACO, etc.).
- Establish and track quality metrics, performance dashboards, and data analysis systems to identify areas for improvement and guide decision-making.
- Collaborate with clinical and administrative teams to implement evidence-based practices and drive improvements in care delivery.
- Manages and supports physician peer review processes by ensuring the collection and analysis of data for provider FPPE/OPPE, scorecards, quality metrics, etc.
Patient Safety & Risk Management:- Implement robust patient safety programs to identify, prevent, and mitigate risks across all departments.
- Lead root cause analyses (RCAs) and failure mode effect analyses (FMEAs) to investigate adverse events, near-misses, and patient safety incidents.
- Ensure the development and implementation of corrective action plans in response to identified risks and safety concerns.
Promoting Just Culture:- Advocate and model a Just Culture framework that encourages open reporting of incidents and near-misses without fear of retribution.
- Foster a non-punitive environment where employees are supported to speak up about safety concerns, learn from mistakes, and contribute to quality improvement efforts.
- Educate staff at all levels about the principles of Just Culture, emphasizing shared accountability for both individual actions and system-level issues.
Regulatory Compliance & Accreditation:- Oversee preparation and lead efforts for hospital accreditation and certification surveys, ensuring the hospital meets all regulatory and quality standards.
- Ensure ongoing compliance with state and federal regulations, including infection control protocols, patient safety standards, and documentation requirements.
- Prepare and submit reports for regulatory agencies and accreditation bodies, ensuring timely and accurate communication.
HCAHPS and Patient Satisfaction Initiatives- Oversee the hospital's Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) program and other patient satisfaction data to ensure accurate data collection, analysis, and reporting.
- Provide staff education on the impact of HCAHPS scores, emphasizing the importance of service excellence and associated reimbursement.
- Utilize patient satisfaction survey data to identify trends, set benchmarks, and develop targeted improvement initiatives.
- Facilitate Patient and Family Advisory Council (PFAC) and Patient Excellence Committee (PEC) to align practices with patient-centered care principles, encourage active involvement of patients and families in care processes, including feedback mechanisms to address concerns and improve services.
Data-Driven Decision Making & Reporting:- Lead the collection, analysis, and reporting of key quality metrics to senior leadership, physicians, and staff, utilizing effective methods to enhance clarity, facilitate understanding, and maximizing practical value.
- Utilize clinical and operational data to identify trends, measure performance, and drive continuous improvement.
- Present findings and recommendations at board meetings and other hospital forums, keeping stakeholders informed about the hospital's quality initiatives and progress.
Education & Staff Development:- Develop and deliver educational programs to promote awareness of quality initiatives, patient safety, and the principles of a Just Culture.
- Provide coaching and mentorship to quality management staff and hospital teams, empowering them to take ownership of quality improvement efforts.
- Collaborate with training departments to ensure all staff receive timely and relevant education on quality standards, safety protocols, and regulatory requirements.
Department Director Functions:- Facilitates alignment between improvement initiatives and the organization's strategic plan; directs the day-to-day execution of the strategies and tactics necessary to successfully improve the outcomes and results of the organization.
- Completes annual performance evaluation for self and employees and implement plans of correction when needed.
- Manages a departmental budget; leads cost efficient and effective operations, creates plan of correction for any operating expenses that deviate more than 10% from budget.
- Uses problem-solving and conflict resolution skills to foster effective work relationships with team members.
- Maintains required competencies for self and all employees within the department.
- Pursues professional growth and participates in a professional organization.
Non-Essential Functions- Performs other duties as assigned.
Qualifications- Bachelor's degree in nursing, healthcare administration, or other clinically focused field with a strong emphasis on analytical skills required
- A minimum of three (3) years' experience in a hospital facility required, quality management and patient safety experience, preferred
- Master's degree in nursing, healthcare administration, or other clinically focused field with a strong emphasis on analytical skills preferred
- Basic Life Support certification required within 30 days of hire
Professional Requirements- Adhere to dress code, appearance is neat and clean.
- Complete annual education requirements.
- Maintain patient confidentiality at all times.
- Report to work on time and as scheduled.
- Wear identification while on duty.
- Maintain regulatory requirements, including all state, federal and local regulations.
- Represent the organization in a positive and professional manner at all times.
- Comply with all organizational policies and standards regarding ethical business practices.
- Communicate the mission, ethics and goals of the organization.
- Participate in performance improvement and continuous quality improvement activities.
- Attend regular staff meetings and in-services.
Knowledge, Skills, and Abilities - Knowledge of CMS and CIHQ standards and regulations.
- Knowledge of and skill in applying and teaching a wide variety of improvement methodologies and tools including but not limited to Lean Management principles, Root Causes Analyses (RCA) and Aggregate RCAs, Healthcare Failure Effects Modes & Analysis (HFEMA).
- Knowledge of the application of the best tool/graph/visual to use for specific data sets and statistical analysis (e.g., pareto charts, fishbone diagrams, process and value stream mapping, etc.)
- Knowledge of system process analysis, quality/process improvement techniques, design, and integration, at a level of complexity associated with integrating processes across multiple departments of an organization.
- Possess a level of analytical ability to problem-solve, evaluate, plan, and direct process improvement projects and benchmarking activities for all clinical and non-clinical departments.
- Skill in organizing and prioritizing workloads to meet deadlines.
- Ability to develop policies and procedures.
- Ability to teach and evaluate clinical performance.
- Ability to compile, code and categorize, or verify information/data
- Strong organizational and interpersonal skills
- Ability to determine appropriate course of action in more complex situations
- Ability to work independently, exercise creativity, and maintain a positive attitude
- Ability to manage multiple and simultaneous responsibilities and to prioritize scheduling of work
- Ability to maintain confidentiality of all medical, financial, and legal information
- Ability to complete work assignments accurately and in a timely manner
- Ability to communicate effectively, with excellent verbal and written communication skills
- Ability to handle difficult situations involving patients, physicians, or others in a professional manner
Physical Requirements and Environmental Conditions - Working irregular hours
- Work in varying degrees of temperature (heated or air conditioned).
- Work under extreme pressure.
- Exposure to blood and body fluids, communicable diseases, chemicals, radiation, and repetitive motions
- Position requires reaching, bending, stooping, and handling objects with hands and/or fingers, talking and/or hearing, and seeing.
