This position is incentive eligible.

Job Summary and Qualifications

This position is responsible for oversight and guidance of Patient Safety and Risk Management initiatives throughout the North Carolina Division. Responsible for managing and coordinating patient safety and risk management initiatives in order to support the market strategic plan and goals and meet HCA quality objectives and standards. In this regard, s/he will have responsibility for facilitating and coordinating activities in:
• Clinical excellence
• Patient safety and risk management
• Systems thinking and reliable design
• Identification and mitigation of patient safety risks
• Safety culture advancement
• Patient safety education
• Measurable reduction in avoidable harm
• Risk management/claims activities
• Process improvement and outcomes management
• Regulatory readiness to include CMS Conditions of Participation, Agency for Healthcare Administration, and The Joint
• Commission
• Project Management to include annual Patient Safety Program

This position coordinates his/her work closely with the Market VP Quality and the Market Chief Medical Officer. S/He is responsible for ensuring facility compliance with The Joint Commission, Centers for Medicare and Medicaid Services (CMS) Conditions of Participation, AHCA, other standards, rules and regulations. Position requires occasional travel as well as temporary placement in hospitals in need of quality leadership.

Major Responsibilities:

Improves Patient Safety by:
• Facilitating the growth of division and hospital knowledge regarding patient safety, risk management, quality, clinical performance and related areas, including the dissemination of "best practices" across the market.
• Leading market-wide standardization in targeted process improvement initiatives, and evaluating success through pre-established criteria.
• Supporting facility's response to Serious Safety Events (SSE)
• Leading proactive patient safety activities to create hospitals that are high reliability organizations, as reflected in reduced errors, elimination of unsafe processes, and increased involvement of staff and physicians toward a culture of safety.
• Contributing to the achievement of business and financial goals through optimal division performance in quality and patient safety.
• Collaborating with and supporting hospital quality, risk, safety and infection prevention leaders to achieve top ranking in national and state publicly reported data initiatives.
• Participating in regular analysis of market quality and risk performance data; planning steps for ongoing improvement.
• Working with Market VP Quality to support data analysis, reporting, and outcomes improvement. Contributing to ongoing enhancement of division quality reporting methods and dashboards.
• Continuously monitoring and evaluating quality outcomes for patient care across the market, while noting trends, and identifying and prioritizing opportunities to improve.
• Assisting with ensuring the data is reported to approved third parties, such as Leapfrog, VON, NHSN, NCDR & STS databases, etc.
• Facilitating and/or leading clinical process improvement teams as needed to achieve quality improvement goals.
• Staying current with NQF, AHRQ, Leapfrog, IHI and other quality performance initiatives.
• Support of Patient Safety Directors through working knowledge of the Serious Event Analysis process. This also includes preparation of PSD staff for presentation to regulatory agencies.
• Promoting a culture that is positive, values individual strengths, takes risks, and is committed to optimal patient care, and compliance with standards.
• Attending HCA-mandated training and meeting all ethics and compliance standards and requirements. Developing and implementing division level projects as directed by Market CMO and Market VPQ.
• Requires ability to function in Quality and Patient Safety Leadership role in an interim capacity in hospitals throughout the market.
• Support hospital leadership throughout the Market with onsite activities including safety rounds, attendance at safety huddle, regulatory rounds, quality meeting attendance and other activities as requested.

Supports HCA by:
• Promoting consistent positive patient interactions that advance the agenda of unparalleled patient service.
• Practicing and adhering to the "Code of Conduct" philosophy and "Mission and Value Statement"
• Performing other duties as assigned

Education & Experience:
• Bachelor's degree. Required
• Master's degree MHA, MBA, MSN, or related field. Preferred
• 4+ years of experience in Leadership in a clinical and quality improvement setting in an Acute Care Hospital. Required
• Management experience. Required
• Previous experience within a multi facility environment. Preferred

Licenses, Certifications, & Training:
• Registered Nurse or Registered Respiratory Therapist. Required
• Certified Professional in Patient Safety (CPPS)
• Must obtain CPPS within 1 year of hire date Required
• Certified Professional in Healthcare Risk Management (CPHRM) Preferred

Knowledge, Skills, Abilities, Behaviors:
• Ability to establish and maintain long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations. Required
• Ability to facilitate group and team process improvement. Required
• Demonstrated ability to work with all levels of management, clinical and IT&S staff. Required
• Excellent analytical and problem-solving skills. Required
• Initiative and ability to work independently and handle multiple priorities. Required
• Strong leadership, creativity, and excellent communication skills, written and verbal, with the ability to tailor the message to individuals and audiences across the organization. Required
• Working knowledge of healthcare laws and regulations Required