Director, Quality and Safety

2510 Cobb Hospital, Inc.•Mableton, GA

About The Position

Responsible for developing a vision and executable plan to attain world class quality and safety processes and procedures across the hospital and all hospital outpatient departments (HOD) and including any associated Health Parks. Accountable to ensure successful development and deployment of the Wellstar Quality and Safety strategy in a manner that supports achievement of Wellstar Quality goals. Bringing patient safety and clinical quality expertise, he/she will partner with leadership, staff and system partners to identify opportunities for short and long-term impact on quality and safety outcomes in alignment with WellStar's strategic plan. Plans, organizes and directs all services and operations of the department which includes quality performance improvement, continuous survey readiness, and infection prevention programs for the hospital. Works collaboratively with hospital Vice Presidents, Directors and Managers, as well as system leadership and peers to align department goals with Hospital and System strategic goals. Oversees daily operations to ensure delivery of high quality services and support and execution of tactics designed to meet the goals. Is responsible for coordinating activities of Quality Committees with appropriate personnel, including Medical Staff, Quality, PI and Peer Review committees. Ensures processes in support of accurate and high performing publicly reported quality data, Wellstar quality goals and applicable data registries. Leads hospital implementation and ongoing support of Lean PI methodology. Serves as an influential champion for the Wellstar Safety First program, supporting a fair and just culture of safety, accountability and organizational learning. Works to effectively integrate functions and coordinate collaboration across the care continuum. Partners with external organizations to ensure regulatory and accreditation standards compliance and to infuse best practices into improvement efforts. The individual in this role will proactively identify opportunities to optimize performance, build internal competencies, foster a strong and empowered team, and create a rigorous approach to quality and safety throughout the organization, with a strong focus on the patient, accountability and appropriate use of resources.

Requirements

Bachelors Nursing or Bachelors Health Science or Bachelors Public Health or Bachelors Business Administration/Management
Masters Nursing or Masters Health Science or Masters Public Health or Masters Business Administration/Management or Masters Other
Cert Prof Healthcare Quality within 1 Year
Minimum 5 years of progressive experience in healthcare quality services and support. Required and
Minimum 2 years experience in managing a team directly. Required or
Minimum 5 years of experience with significant project or functional leadership within quality services.
Previous experience with proven leadership in regulatory and accreditation survey readiness, quality improvement and patient safety in a large acute care system or facility required, including demonstrated ability in interpreting quality metrics to lead actionable change. Required and
Strong experience with patient safety event management, including conducting root cause analysis and facilitating creation of effective, timely action plans. Required and
Experience leading improvement work using a scientific methodology Required and Lean management system and Lean Production System methodology.
Strong interpersonal skills with the ability to communicate and work with all levels of healthcare providers including physicians.
Ability to perform duties and responsibilities promptly and consistently with little direct supervision.
Ability to execute a plan and use project management methodology.
Ability to plan and direct activities of others and provide feedback regarding outcomes or performance.
Ability to work collaboratively with other departments within and outside the Hospital.
Ability to judge the appropriate action in response to changes, circumstances, or problems.
Experience in data collection, analysis and project management required.
Strong computer skills required.
Excellent communication, presentation and organization skills required.
Working knowledge of data collection methodologies, interpretation/analysis and decision support databases.
Exposure to workflow in event management systems with the ability to interpret and utilize trended event data to improve safety.

Nice To Haves

Experience coordinating with and reporting data to a Patient Safety Organization (PSO) Preferred and
Experience managing and/or monitoring infection prevention functions Preferred

Responsibilities

Oversees the development and implementation of the hospitals Performance Improvement Plan in accordance with regulatory requirements, in response to hospital improvement opportunities, and in coordination with the WellStar strategic plan and goals
Assists hospital departments in the development of their Quality Assurance Performance Improvement (QAPI) goals and action plans. Ensures departments provide routine reporting of progress.
Conducts an annual assessment of the hospital PI Plan, providing a written report, and revising the plan as indicated
Collaborates with Hospital and System Leadership to align priorities and resources with hospital and system goals
Plans, implements and provides appropriate support for key clinical quality and safety initiatives
Provides strategic direction and guidance on quality, safety and accreditation to operational leaders and timelines for new guidelines, regulations and processes
Ensures adherence to Standard Work applicable to the roles and responsibilities within the department, as designed by the hospital and/or system.
Effectively utilizes and collaborates with the corporate Enterprise Intelligence and Public Reporting teams on the analysis, interpretation and communication of publicly reported quality measures
Monitors clinical and performance outcomes via benchmark analysis and facilitates accountability via defined expectations and goals
Develops area-specific strategic plans and works with managers to facilitate goal achievement
Facilitates standardization and prioritization of operations to achieve hospital objectives while assuring continuous quality improvement and outcome excellence
Serves as hospital Patient Safety Officer, providing oversight of comprehensive patient safety program
Collaborates with System Leadership to implement and evaluate the Safety First Program including, but not limited to High Reliability Leadership Methods (Daily Safety Huddles, Leadership Walk-Arounds, Fair and Just Culture Accountability, providing and receiving 5:1 Feedback, Safety Absolutes) and Error Prevention Techniques
Collaborates with System Leadership to oversee and implement robust, highly effective safety event management processes according to Wellstar Event Reporting policy (EC-60-01), including but not limited to: identification; reporting; cause analysis; development of corrective action plans with measures for effectiveness; and tracking of cause analyses and associated action plans
Collaborates with System to oversee the deployment of unit level patient safety programs
Serves as consultants, subject matter experts, and facilitators, as appropriate regarding quality, performance improvement and patient safety initiatives including, but not limited to sentinel event alerts, National Patient Safety Goals (NPSG), Failure Mode and Effects Analysis (FMEAs), mortality reviews, system goals, Hospital Improvement Innovation Network (HIIN), and process improvement projects. Ensures appropriate parties are involved with timely follow-up and reliable documentation
Supports hospital participation in the Patient Safety Organization (PSO)
Coordinates and facilitates survey activity including, but not limited to Joint Commission accreditation, CMS and State regulatory surveys. Provides consultative support for disease specific certification surveys
Coordinates and oversees the use of tracer and mock surveys through utilizing electronic database to provide leadership trends of the findings
Assures that they are conducted as required with timely reporting and support to hospital departments and managers. Participates in system-wide mock survey activities
Routinely reviews regulatory and accreditation standards. Supports Functional Area Leaders, medical staff and others to ensure compliance by providing education, and assisting with proactive identification of non-compliant practices
Identifies high risk areas for regulatory compliance and facilitates education and process improvement efforts to create alignment and compliance
Accountable for ensuring that action plans are developed to address deficiencies identified by regulatory agencies are fully executed by required deadlines and that actions are monitored for effectiveness and sustained improvement.
Communicates Survey Readiness success and potential barriers with Administrative, Hospital, and Physician Leaders
Oversees Daily Operations of the Department
Oversees and directs employee and talent functions for the department which includes interviewing, hiring and orienting staff in collaboration with managers. Responsible for team building across departments
Oversees the completion of performance evaluations in a timely manner.
Ensures appropriate time keeping and responsible for managing schedules/time and attendance
Conducts regular meetings with direct reports and supporting individual developmental goals
Develops operating and capital budgets in coordination with hospital and system initiatives; monitors to ensure variance analysis and resolution
Implements new or revised programs of the department.
Supervises the processes for data abstraction, review and management for Medical Staff Quality Review, Peer Review, Process Improvement, and registries
Coordinates Committee activities
Directs the work of the Committee and implementation of improvements
Maintains Committee documents
Oversees maintenance of confidentiality of all related information
Performs other duties as assigned
Complies with all Wellstar Health System policies, standards of work, and code of conduct.