Director of Quality & Patient Safety

Overview

In a joint venture partnership with UT Health System,Ardent operates UT Health East Texas in Tyler, Texas. UT Health East Texas is comprised of UT Health Tyler (the area’s only Level I trauma center), UT Health North Campus, UT Health Athens, UT Health Carthage, UT Health Henderson, UT Health Jacksonville, UT Health Pittsburg, UT Health Quitman, UT Health Air1/EMS, UT Health East Texas Rehabilitation Hospital, UT Health Long Term Acute Care, UT Health Hope Cancer Center and UT Health East Texas Physicians. With 974 licensed beds, UT Health East Texas is advancing healthcare, together.

POSITION SUMMARY

The position of Quality and

Patient

Safety

Director

at UTHET is accountable for

assisting

the organization to improve quality, safety, and reduce operational risk exposure through performance improvement processes and meeting regulatory and accreditation requirements. They will

assist

in the implementation of UTHET’s Quality/Clinical effectiveness function. This position supports a culture of high reliability and the measurement of care quality

identifying

opportunities and executing on strategies for performance improvement in the following areas of the organization:Outcomes -

highly reliable

processes, deli

vering exceptional outcomes and/

or

optimal

healthSafety – Deliver the safest care to patients driven through leadership and a culture of high reliabilit

yAccreditation-Ensures all regulatory requirements are managed and highly functionalExperience of Care - relationship-centered care grounded in empathy, dignity,

respect

and collaboration

Responsibilities

Support a proactive, comprehensive strategic Quality agenda that inspires caregiver engagement, inter-professional collaboration, the iden

tification and use of evidence-

based practice and management among all entities in the system while differentiating

UTHET

as a high reliability organization nationally.Provides

accurate

and meaningful data to teams,

committees

and physician groups by understanding data dictionaries and using appropriately, using self-coded data sheets,

assisting

in determining

appropriate data

to collect by asking right questions and

identifying

correct populations, and using working knowledge of existing databases to obtain data already being collected.Appropriate knowledge and application of basic statistical tools, such as, standard deviation, frequency distributions, histograms, and

Pareto charts

.Actively

participate

in divisional meetings, processes, and activities to ensure Quality functions are

disseminated

consistently throughout the division.Chair and lead the local Performance Improvement Committee

.Acts as a liaison between the Performance Improvement Committee and the Governing Board, to ensure all CMS

CoPs

are met.Applies quality improvement methodologies as a quality representative/facilitator for PI Teams and as a consultant to provide basic CQI or statistical tools.Evaluates and makes recommendations for system improvements using quality data,

event

and regulatory compliance reports.Provides project management to assigned teams by providing leadership to focus areas and by

utilizing

facilitation and assessment skills to develop evidence-based initiatives.Regulatory Compliance:Drives all regulatory functions on the local level.Applies a current working knowledge of regulatory compliance standards as

appropriate to

assignment or specialty.Participates in all divisional regulatory functions and standards.Leads the participation and management of the Internal Quality Survey process, including

timely

and

appropriate response

to action plans.Lead and drive the sustainability efforts for all IQS and TJC action plans to ensure compliance is

maintained

and practice changes are hardwired

.Provides advanced consultation and support by collaborating with

peers

throughout the corporation to develop methods and plans to meet standards, participating in the writing or development of new policies, procedures and guidelines, researching literature and outside sources to identify new methods, technologies, or approaches for compliance, ensuring compliance to regulatory support and assessing compliance to standards to ensure a safe and consistent care environment to multiple areas and settings.Patient Safety:Leads Mission Zero: Our Cultur

e of Safety on the local level, based on division standards and expectations.Leads and/or functions as the

Risk Manager on the local level, based on division standards and expectations.Applies a current working knowledge of national, local, and system patient safety standards and trends as

appropriate to

assignment or specialty.Leads PSEA and RCA efforts and reports to the Ardent PSO, per requirements.Participates in the division SENT process for reporting safety events.Participates in the division safety event classification process.Provides collaboration and consultative support to Risk Management, Compliance, Medical Staff, Nursing, and others by compiling reports with recommendations from

appropriate sources

,

participating

in maintenance of applicable Safety Plans, networking across departments and facilities to achieve

objectives

and goals,

participate

or facilitate patient safety improvement teams, and engages and interacts with staff at all levels to encourage ownership of initiatives.Practice Standardization and Policies:Advocate and support standardization by educating focus areas to centrally developed policies, procedures, processes, and forms and assisting/

participating

in corporate teams with the development of policies, procedures, processes, and forms.Participate in development, implementation, revision, and review of policy, procedures, protocol, guidelines, and forms, when

appropriate for

focus areas.Education:Provides education to focus areas

regarding

Quality Monitoring and Improvement, Regulatory Compliance, Patient Safety,

Risk Management, Medical Staff Services

and Practice Standardization and Policies.Informatics, Data and AnalyticsSupport quality measurements for internal use.Support and distribute standardized reports that are developed centrally to ensure consistency in data management and reporting across the division.Support the deployment and optimization of the electronic health record to maximize safety, quality outcomes, clinical

effectiveness

and efficiency.Advance, with others, the use of predictive analytics and deep learning computing to improve the health,

experience

and quality of care of those we serve.

SUPERVISION:

Depending on

the

facility, the director may

be responsible for

3-5 direct reports.

Qualifications

Education and Experience:Required:

Bachelor's degree in Business

, Healthcare Administration, Public Health or other

business related

field. Education must be obtained through an accredited institution and will be verified.E

xperie

nce leading successful Quality I

mprovement projects

.Experience with change management with the ability to provide leadership in the adaptation and implementation of new processes and /or technology that enhance Quality.Effective verbal, written and interpersonal communication skills.E

xperience overseeing patient safety programs

.E

xperience leading teams

.Trained in improvement science (i.e., Six Sigma, Lean, UT System CSE or DMAIC)Experience working in a complex health system (hospitals, ambulatory clinics, post-acute care, etc.)Experience with external entities that drive and support Quality approaches and standards, including government agencies, academic institutions, universities and related organizations of higher education, and other public institutions is preferredOne of the following certifications is preferred-CPHQ, CPXP, CPSP, CPHRM