Director - Quality Mgmt And Patient Safety

BASIC PURPOSE OF THE JOB
Develops, coordinates, implements, maintains and supervises the quality management department and infection control programs.
REPORTS TO

• Vice President-Patient Care Services

JOB REQUIREMENTS
Supervisory Responsibilities: Yes
Minimum Education: Bachelors requried; Masters preferred
Degree: Degree in Nursing, Health Information Management or related clinical field
License/Certification Required: Registered Health Information Administrator (RHIA) or Certified Professional in Healthcare Quality (CPHQ); TN or Compact RN Licensure Required.
Minimum Work Experience: 5 years in quality management or an acute care setting, pediatrics preferred. Infection control experience and certification perferable
REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES

• Strong verbal and written communication skills.
• Excellent leadership, organization and time management skills.
• Strong computer skills including proficiency in MS Office.
• Strong analytical skills.

DUTIES AND RESPONSIBILITIES

• Demonstrates ongoing collaboration with medical staff leadership, other clinical and administrative leadership regarding the development and implementation of priorities to improve clinical outcomes, reduce preventable patient harm, and alignment with strategic initiatives.
• Provides oversight to the provision and support of current best practice methods to improve Patient Safety and clinical outcomes which emphasizes human factors in a just culture.
• Serves as internal consultant and educator to hospital and medical staff on performance measurement for compliance with external requirements such as The Joint Commission, Vermont Oxford Neonatal Network, nursing Magnet clinical measures, etc.
• Oversees ongoing review for compliance, effective processes, and improved relevancy for ongoing professional performance evaluation (OPPE) and peer review as required by clinical leadership.
• Serves as facilitator, coordinator, and/or educator as needed in the root cause analysis process and the pro-active risk analysis process.
• Oversees the accuracy and timeliness of multiple measures and databases utilized in quality management and infection control activities.
• Serves as ETCH quality/Patient Safety liaison in external pediatric groups such as Children's Hospital Association (CHA) Forums and the Solutions for Patient Safety (OCHSPS) Eliminating Serious Harm project.
• Serves as the designated CBISA reporter for the department. Reports benefit activities, communicates benefit stories, calculates event detail and enters information into Lyon Software (CBISA) program. Completes reports monthly with an understanding that all fiscal year entries be completed no later than August 1 of the next fiscal year.
• Maintains an effective surveillance system by monitoring daily patient admissions, lab reports, patient discharge medical records, and multi-departmental patient care reports.
• Demonstrates by example and sets departmental expectations of excellent internal and external customer service which includes data accuracy, relevance, and timeliness for decision support.
• Demonstrates by example that the QM Department shall view its purpose as a support function to leaders and front-line staff in promoting clinical excellence and Patient Safety.
• Actively participates in the New Employee Orientation and Leadership On-Boarding process for all new employees and new leaders in their department/unit.
• Effectively leads and participates in the performance management of staff.
• Continually evaluates the value of tasks in order to add new priorities and discontinue low-yield tasks.
• Utilizes hospital resources and time respectfully and accountably and willingly accepts any other assignment that may be requested.

PHYSICAL REQUIREMENTS

• Note: Reasonable accommodations may be made for individuals with disabilities to perform the essential functions of this position.
• Light lifting, pushing and pulling is required for 1-20 lbs occasionally and frequent moving of objects of less than 10 lbs is required. Frequent sitting with some walking, standing, squatting, bending, and reaching is required. Keyboard/computer use and/or repetitive motions may be required.

Come work where you can make a difference everyday.