Quality and Patient Safety Director

In collaboration with the Board of Managers, Medical Executive Committee, and Executive Leadership Team, the Director of Quality and Patient Safety is responsible for the strategic development and execution of enterprise-wide quality management and patient safety plans and initiatives. Leads the operations of quality, risk, infection control, and medical staff services including the credentialing functions, professional practice evaluations, and medical staff development (extensive involvement of the Director of Medical Affairs is vital to this role). Serves as a system wide resource for CMS Conditions of Participation and HFAP quality, patient safety and risk management standards, NE DHHS, and clinical performance improvement.

1. *Commits to the KRMC mission, vision, values and goals and consistently demonstrates our core values.

2. *Participates with the Governing Body, management, medical staff and clinical leaders in the hospital’s decision-making process.

3. Serves in tandem with the CNO as the administrative partner to the President of the Medical Staff and Director of Medical Affairs and is an active participant in Senior Leadership Team and Clinical Leadership Team, and appropriate medical staff, leadership, and departmental meetings.

4. *Oversees the departmental budgetary procedure to ensure proper operational and capital planning, appropriate and efficient use of resources, and consistent compliance to budgetary and fiscal controls.

5. *Implements an effective, ongoing program to measure, assess and improve the quality of nursing care delivered to patients.

6. *Implements an effective, ongoing program to measure, assess and improve the quality of nursing care delivered to patients.

7. *Assumes 24/7 accountability for the direction of appropriate provisioning of services and providing resources across areas of responsibility.

8. *Accountable for the efficient delivery of patient care by leading the development, evaluation, and utilization of safe, cost effective, high quality clinical practices.

9. Collaborates with hospital leaders in developing, implementing, reviewing, revising and monitoring organization wide performance improvement activities, and most notably service and quality.

10. Reviews monthly performance improvement activities with established indicators and sees that corrective actions are taken when underperformance is identified.

11. Collaborates with hospital leaders in developing, implementing, reviewing, revising and monitoring organization wide performance improvement activities, and most notably service and quality.

12. Responds to operational issues impacting the delivery of timely, efficient, and quality patient care services.

13. Addresses and supports our culture and ensures safe practices that do not harm others or interfere with the planned course of medical care.

14. Ensures that clear, concise, and current written policies and procedures are available to assist the staff and minimize risk factors.

15. Recommends modifications, additions, or deletions to staffing plans across the areas of responsibility to ensure reasonable hours and acceptable working conditions to provide optimal coverage.

16. Maintains close coordination of the departments served in alignment with all other departments of KRMC to ensure continuity and collaboration of services.

17. Ensures that all aspects of patient care occur in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors.

18. Develops and approves job descriptions within the scope of responsibility.

19. Effectively leads and administers the performance appraisal system; and provides coaching, leadership and mentorship in the development of others.

20. Gives routine performance feedback, conducts annual performance reviews for personnel, and works in collaboration with HR and the senior leadership team to ensure the reward and recognition system is competitive.

21. Builds and leads a culture of teamwork and respect throughout areas of responsibility and across departments, engaging effectively with all stakeholders, e.g. physicians, staff, outside contractors, and the people served.

22. Responsible for cost controls to ensure effective use of funds expended from areas of fiscal responsibility.

23. Initiates and supports problem-solving groups and lean principles that proactively resolve issues.

24. *Accountable for facilitating organization wide quality improvement activities including but not limited to the Quality Improvement Plan, priorities, and ongoing annual review with the Medical Executive Committee and Board of Managers, Ongoing Professional Practice Evaluation & Focused Professional Practice Evaluation (in collaboration with the President of the Medical Staff and Director of Medical Affairs).

25. Ensures compliance with regulations governing the Hospital and health system and rules of accrediting bodies (i.e. NE DHHS, ACHC, CMS), by maintaining extensive knowledge of the requirements and by continually monitoring the activities and processes tied to each standard.

26. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.

27. Participates in and/or leads meetings, committees, strategic planning and lean projects as assigned.

28. Performs other related projects and duties as assigned.

education/experience:

• Bachelor’s degree in a clinical discipline or commitment to enroll in an accelerated bachelor’s or master’s program.
• Experience in a role with responsibilities related to healthcare quality, risk management, or patient safety.
• Clinical patient care experience in a hospital setting.
• CPHQ or CPHRM certification(s) preferred.