Job Description:A brief statement of the position, including the general job duties.
Provides leadership in the development of a culture of safety and the measurement of the quality of care identifying opportunities and strategies for performance improvement. Directs and coordinate Quality Improvement Program for the health system, including continuous process improvement, patient relations, accreditations, regulatory compliance, patient safety, infection control, and support for medical staff peer review. Develops strategic plans for improved quality. Works with senior management to ensure survey readiness. Has primary oversight of the health system’s patient safety program. Directs others within the health system toward process improvements that will support the reduction of medical/health care errors and other factors that contribute to unintended adverse patient outcomes. Provides leadership for safety assessments, coordinates the activities of the patient safety team, educates other practitioners on the systems-based causes for medical error, consults with management and staff, and communicates literature-based ideas regarding effective patient safety strategies to others within the organization. Acts as a health system-wide expert and resource in quality improvement.
Required: Masters Degree in Nursing or related field.
Preferred: Doctorate in related field
Required: CA RN
Preferred: Certified Professional in Healthcare Quality (CPHQ)
Required: Minimum five years working in healthcare Quality Improvement or related field.
Specific Skills, Knowledge, Abilities Required
Computer skills, to include data entry, spreadsheets, graphics, information systems. Ability to collect, analyze and disseminate data, including financial and statistical data.
Knowledge of performance improvement tools, and the ability to use them effectively.
Excellent verbal and written communication and interpersonal skills; experience presenting data and information to physicians and other clinical staff as directed.
Experience working with clinical outcomes data systems and resource management.
Ability to set goals and work independently and efficiently with minimal supervision; ability to prioritize fluctuating workload and times to meet position demands.
Ability to work in a fast-paced environment and manage multiple meetings and projects.
Knowledge of regulatory standards including Joint Commission, Medicare (CMS) and Title 22 (state) requirements.
Data collection and analysis.
Essential Leadership Responsibilities
Demonstrates compliance with Code of Conduct and Compliance Policies and takes action to resolve compliance questions or concerns and reports suspected violations.
Develops and achieves departmental goals and objectives. Establishes, implements and maintains policies and procedures.
Coordinates care, treatment and services among the hospital system’s different programs, service sites, and departments and physicians and integrates services within.
Collaborates across clinical and operational areas in maintaining emergency management procedures.
Provides for a sufficient number and mix of qualified and competent staff to support safe, quality care, treatment and services. Determines qualifications, competence levels and standards of performance.
Selects, trains/orients, directs, coaches, evaluates effectiveness and competence of staff either directly or through subordinate supervisor to promote safety and quality.
Designs work processes and changes existing processes to focus individuals on safety, quality, and improves performance of the hospital system and involves staff and patients in the process.
Provides for equipment, supplies, resources and space needed to support the safety and quality of care, treatment and services. Participates in selecting outside sources for needed services.
Ensures compliance with recommendations and requirements from external agencies such as accreditation, certification/licensing and other regulatory bodies.
Ensures that staff consistently provides safe and high quality patient care and/or other support services that are valued by patients, physicians and each other.
Achieves a high level of employee, patient and physician engagement/satisfaction.
Ensures efficiency, productivity and sufficient financial resources, including adequate reserves, to meet all current and projected financial requirements.
Role models the organization’s mission, vision, values and True North. Complies with and ensures hospital-wide Supporting Commitments are adhered to.