CHI · 1 day ago
Director Quality - Patient Safety
CHI is a healthcare organization focused on improving patient care and outcomes. The Director of Quality - Patient Safety is responsible for leading the design and implementation of performance improvement and patient safety plans, ensuring effective strategies are integrated into organizational processes.
Health CareHospitalMedicalNon Profit
Responsibilities
Design, coordination, implementation and management of the Organization's Performance Improvement (PI) and Patient Safety plans
Identify opportunities for improved patient care and outcomes and reductions in harm, with the implementation of evidence-based practices
Provide leadership in defining, implementing and integrating quality, safety, service and efficiency strategies into the plans, policies, and organizational processes that affect the organization's operations and strategic direction
Establish performance improvement goals annually with relevant stakeholders
Ensure the Performance Improvement Plan and the hospital-focused projects for the year are implemented and their effectiveness is evaluated annually
Develop and implement processes and formats which support data collection, aggregation, analysis, and action planning
Assure data is managed appropriately and disseminated to appropriate leadership staff
Provide leadership in developing quality improvement and patient safety training programs and coach organizational clinical/service lines and operational/support departments in quality improvement principles
Implement and oversee the organization-wide patient safety program and manage the reporting, data analysis and evaluation as outlined in the Patient Safety Plan
Oversee the events reporting process, root cause analyses, investigations and requests from the claims team (including management of subpoenas, Summons and Complaints, and coordination of legal documents related to hospital liability)
Participate in system office initiatives and programs to mitigate risks in the facility which have been identified at other hospitals, resulting in reduced costs, adverse patient outcomes and ultimately safer patient practices and care
Collaborate with the Medical Staff and Organizational Leadership to develop and enhance safe patient care while achieving optimal outcomes, including the organization’s peer review program and ongoing and focused practitioner evaluation
Provide leadership and is responsible for accreditation and regulatory survey readiness
Oversee mock survey tracers to assess survey readiness
Provide education to staff and providers on regulatory compliance
Organize required staff to develop responses to survey deficiencies and submit responses to the appropriate accreditation or regulatory agency
Have overall accountability for assigned work group relative to operational goals, personnel requirements, and budgetary constraints
Qualification
Required
Bachelor's degree in healthcare or five (5) years of related job or industry experience in lieu of a degree
Minimum of five (5) years of progressive management responsibility in a health care setting
Two (2) of which is related to managing an acute care organization's Quality Improvement Program
Minimum of two (2) years of clinical, patient care experience or equivalent
Experience developing and implementing clinical, service and operational process improvement initiatives, both small and large scale
Experience with the event reporting process, root cause analyses, and event investigation/review
Experience with patient complaint/grievance investigations and prompt resolution
Five (5) years' experience in Quality Management can be used in lieu of state license
State License in a clinical field
Certification required in one of the following (or within 24 months of hire): Certified Professional in Healthcare Quality (CPHQ), Healthcare Quality Mgmt (HCQM), Cert Prof Healthcare Qual (CPQPS)
Company
CHI
Catholic Health Initiatives, a nonprofit, faith-based health system formed in 1996 through the consolidation of four Catholic health systems, expresses its mission each day by creating and nurturing healthy communities in the hundreds of sites across the nation where we provide care.