Reporting to the VP Quality Management, will develop and implement a comprehensive quality and patient safety system.  The goal is to foster clinical excellence, promote innovation and ensure patient safety by participating in clinical initiatives that promote evidence-based practices.  The Director of Quality Management will provide leadership and direction for quality improvement, patient safety, hospital accreditation, and cultural diversity departments. 

The Director of Quality Management will support the implementation and monitoring of programs and activities designed to ensure that the hospital incorporates methods to improve the safe administration of care while promoting a culture that promotes patient safety to be of upmost importance.

Responsible for ensuring that the quality management and patient safety system conforms to DNV/ISO standards by serving as the Management Representative.

SHIFT AND SCHEDULE

Full Time: 8:00 AM – 5:00 PM

ESSENTIAL FUNCTIONS/PERFORMANCE EXPECTATIONS

Performance and Process Improvement/Data Analytics

• Establish governance structures and processes to ensure adherence to workflows and policy.
• Engage clinical leadership in determining relevant performance measures and benchmarks.
• Develop quality metrics for ongoing professional practice evaluations (OPPE).
• Design solutions to address opportunities based on benchmarking, goal comparison, data analysis and corrective actions.
• Incorporate evidence-based practice into proposed interventions.
• Implement strategies to address barriers across the organization.
• Evaluate the effectiveness of the organization’s quality improvement initiatives and make adjustments as required for ongoing success and sustained results.
• Develop dashboards and scorecards incorporating metrics (national or payor benchmarks) tailored to strategic or operational goals.
• Communicate the impact of quality initiatives on federal/state payment/reimbursement programs (Inpatient Quality Reporting (IQR) program, Outpatient Quality Reporting (OQR) program, HAC Reduction program, VBP, Hospital Readmission Reduction (HRR) program, eCQM submission, RAC requirements and state cancer registry).
• Evaluate voluntary external standards to advise the organization on whether these advance or impede the achievement of strategic goals. Examples include service line awards/certifications, Leapfrog and clinical registries). Current clinical registries include National Surgical Quality Improvement Project (NSQIP), Vascular Quality Improvement (VQI), American Joint Replacement Registry (AJRR) hips and knees, American Academy of Orthopedic Surgeons Registry (AAOS) shoulder and spine, and Society of Thoracic Surgeons Registry (STS).

Patient Safety

• Conduct a biennial culture of patient safety survey.
• Ensure that processes are created to address gaps identified in the survey findings.
• Apply root cause analysis (RCA), FMEA, surveillance activities and risk assessments to identify and evaluate patient safety risks.
• Utilize findings from RCA, gap analysis, surveys and audits to design appropriate interventions.
• Assist in reviewing medical record documentation for appropriateness of care and advise leadership accordingly.
• Work with Risk Management department to track and trend patient safety issues, develop plans for improvement and ensure appropriate reporting to state and federal agencies.

Regulatory and Accreditation

• Provide leadership and guidance in the development and implementation of the Quality Management/Patient Safety System that involves all department and services, focuses on indicators related to improved health outcomes and reduction of medical errors.
• Intervene when necessary, involving senior leadership, to hold owners accountable for actions and established deadlines.
• Provide analysis and interpretive guidance of federal and state regulations/standards.
• Establish a continuous accreditation survey readiness process that incorporates accountability and participation by all levels of staff.
• Provide oversight for presurvey, onsite survey, and post-survey accreditation activities.
• Oversee the coordination, submission and monitoring of corrective action plans associated with accreditation and/or certification of service lines.
• Ensure that an electronic document management system is maintained.
• Assess policies to ensure that they reflect applicable regulations/standards.

Patient Satisfaction

• Create a culture of passion and commitment for exemplary patient experience, working closely with Patient Experience Director to ensure patient perception of quality initiatives are aligned.
• Collaborate with Midland Health leaders to achieve goals exceeding national benchmarks including CMS and LeapFrog

EDUCATION AND EXPERIENCE

• A master’s degree in a healthcare field (nursing preferred).
• 5-10 years of experience in a senior leadership position with a strong foundation in quality and patient safety.
• Moderate proficiency in Microsoft Office applications.
• Cerner experience is a plus.

PHYSICAL REQUIREMENTS

To perform this job successfully, an individual must be able to perform each essential responsibility satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The individual must be able to:

• Stand, walk, sit, stoop, reach, lift, see, speak and hear. Lifting is limited to 35 lbs. for clinical staff and to 50 lbs. for non-clinical staff. The individual must use an assisted-lift device or get another individual(s) to assist with the lift that is over these maximum limits.