This position serves as Senior Leader and collaborates with the Senior Leadership team on strategic planning, goal setting, department evaluations, and the implementation of strategic initiatives for the respective departments. The Director of Quality and Patient Safety works in partnership with Lakeside Medical Center administrative and medical staff leadership, provides leadership in the development of a culture of safety and measurement of the quality of care identifying opportunities and strategies for performance improvement. Directs and coordinates accreditation, policy and regulatory affairs initiatives for Lakeside Medical Center, serves as the Joint Commission liaison in conjunction with the AVP, Lakeside Medical, Director of Nursing and ACMO, and other pertinent regulatory agencies.
Initiates and oversees the development of a comprehensive safety and quality improvement, HCAHPS and Patient Safety Culture Survey program inclusive of the analysis and trending of data related to initiatives.
Provides strategic oversight of patient safety and quality improvement committees with accountability for distribution of organizational communication vertically and horizontally within Lakeside Medical Center and vertically with the Healthcare District key leadership team as appropriate.
Initiating and overseeing proactive evaluation and redesign of systems to improve care processes to prevent future errors.
Provides overall direction necessary to ensure that clinical services are provided in accordance with standards established through state and federal regulations and The Joint Commission accreditation standards including the National Patient Safety Goals that are evidence-based.
Provides strategic oversight of proactive and reactive patient safety activities including root cause analyses, failure mode effects analyses and Sentinel Event alerts. Collaborates with the Risk Management Team on the reporting, investigation, analysis and corrective action planning on medical errors and near misses. Works with Key Leadership and Risk management Team to facilitate process change.
Assesses compliance with accreditation standards and regulations related to clinical care in collaboration with entity leadership and staff. Identifies areas of vulnerability and directs the development of strategies to enhance compliance.
Performing Patient Safety Rounds that establish psychological safety and empowerment to staff to identify and participate in resolution of patient safety concerns.
Supporting and encouraging error reporting throughout the organization through a non-punitive just error reporting system.
Serving as an Ambassador of Safety to community by facilitating joint efforts to eliminate preventable harm.
Ensuring that information is submitted for Leapfrog in a timeframe required.
Providing analysis and identifying trends utilizing EHR data.
Assesses and reports quality indicator outcomes as appropriate to the facility and line of service. Designs education as needed to enable areas of responsibility to utilize quality data.
In collaboration with clinical staff and service managers, participates in the monitoring, reporting, and improvement activities related to clinical care, health care quality/safety initiatives, accreditation and regulatory requirements.
Coordinates the facility’s Joint Commission accreditation activities including leading teams and committees in compliance activities. Provides leadership education on standards and coordinates ongoing compliance review activities and corrective actions. Coordinates all Joint Commission reporting.
Participates and coordinates various committees and projects to facilitate the compliance of regulatory requirements.
Regularly communicates quality/safety activities to leadership and staff.
Emergency duty may be required of the incumbent including but not limited to: working in special needs or Red Cross shelters, performing other emergency duties responding to threats or disasters, man-made or natural as required.
Education: Bachelor’s Degree in nursing, healthcare administration, management or a related discipline. Master’s Degree in same preferred.
Experience: Five (5) years of progressive administrative leadership experience in quality and patient safety activities with demonstrated ability in design and implementation of performance improvement activities in a health care setting including skillful application of continuous quality improvement and patient safety sciences. Responsible growth in acute care facility required. Experience in Lean-Sigma as an improvement methodology is preferred.
Certification: Certification in Healthcare Quality preferred.