Director Quality & Safety - Patient Safety - Days - FT

Job Description:

Quality Improvement and Support

Supervise Performance Improvement Specialists that provide support to the Memorial Health System in meeting acute and ambulatory quality/safety priorities

Develop and maintain a process that engages acute and ambulatory leaders in the periodic assessment and prioritization of System-wide quality/safety initiatives

Establish and facilitate quality improvement collaboratives that identify unwarranted variation in care and support the adoption of best practices to achieve and maintain exceptional outcomes

Support the clinical effectiveness programs

Assist the System Chief Nursing Officer in supporting nursing quality and improvement

Infection Prevention

Supervise the coordinator of regulatory measures

Develop a comprehensive, sophisticated, but simple to use data management system that effectively allows System and Care Site leaders to monitor, evaluate, and improve quality and safety

Provide effective data tools, training, analytics, and reports that meet key customer requirements (System, Care Sites, regulatory agencies, etc.)

Clinical Risk Management and Patient Safety

Develop and maintain a strong and standardized patient safety event response system improving system resiliency through prevention, detection and correction

Identify and mitigate organizational risk to safe patient outcomes

Coordinate safety efforts to ensure Memorial Health is established as a learning organization and ensures a just culture and non-punitive response to errors while driving accountability

Develop and maintain standardized programming focused on prevention of safety events and continuous learning

Patient and Customer Experience

Develop and maintain programs that enhance patient experience as measured by the various agencies reporting on hospital, clinic, and health plan patient experience

Healthcare Accreditation Coordinator

Supervise the coordinator of healthcare accreditation

Develop and maintain a quality measures abstracting services for the system that meets regulatory/accrediting reporting requirements for required publicly-reported measures

Develop and maintain an effective electronic clinical quality measurement (eCQM) process that meets regulatory/accrediting reporting requirements and can be expanded as necessary to meet new or changing reporting requirements

Pay for Performance

Monitor, evaluate and improve performance on federal pay for performance and penalty programs (e.g., Value-Based Purchasing, Hospital-Acquired Conditions, Readmissions)

Work in collaboration with Population Health representatives to assess, negotiate, and perform on commercial pay for performance contracts

Continuous Survey Readiness

Assure that hospital and departments of the hospital have the necessary resources, tools, training, processes and support to maintain continuous survey readiness

Provide technical assistance and consultation as requested for rectifying any regulatory or accreditation concerns

Performs other duties as assigned

Required Qualifications:Education:

Master's Degree from an accredited school of nursing, master's degree in nursing, business, or healthcare administration.

Licensure:

CPHRM and CPHQ

Experience:

Ten (10) years nursing, 7 years leadership

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