Director Quality Patient Safety
US-TX-SUGAR LAND
commonspirit_careers
Req #: 410640
Type: Day
|
|
||||||||||
|
|||||||||||
Overview: St. Luke's Health-Sugar Land Hospital offers the latest technology and treatments for residents of Fort Bend County and Southwest Houston. Our services range from heart care and neuroscience to robotic surgery. Our recently opened Family Birthing Center offers incomparable care and amenities in a spa-like environment to provide a VIP-Very Important Pregnancy-experience. Since 2008, our experienced doctors, nurses, and support staff have provided expert care to support our community. Responsibilities: This position is responsible for the design, coordination, implementation and management of the Organization's Performance Improvement (PI) and Patient Safety plans and identifies opportunities for improved patient care and outcomes and reductions in harm, with the implementation of evidence-based practices. Provides 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. Essential Key Job Responsibilities Establishes performance improvement goals annually with relevant stakeholders. Ensures the Performance Improvement Plan and the hospital-focused projects for the year are implemented and their effectiveness is evaluated annually. Develops and implements processes and formats which support data collection, aggregation, analysis, and action planning. Assures data is managed appropriately and disseminated to appropriate leadership staff. Provides leadership in developing quality improvement and patient safety training programs and coaches organizational clinical/service lines and operational/support departments in quality improvement principles. Implements and oversees the organization-wide patient safety program and manages the reporting, data analysis and evaluation as outlined in the Patient Safety Plan. Oversees 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). Participates 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. Collaborates 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. Provides leadership and is responsible for accreditation and regulatory survey readiness. Oversees mock survey tracers to assess survey readiness. Provides education to staff and providers on regulatory compliance. Organizes required staff to develop responses to survey deficiencies and submits responses to the appropriate accreditation or regulatory agency. Has overall accountability for assigned work group relative to operational goals, personnel requirements, and budgetary constraints. Qualifications: Required Education and Experience: * Bachelor's degree in a healthcare-related field 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. Required Licensure and Certifications: Current State License in a clinical field. Five (5) years' experience in Quality Management can be used in lieu of state license. Certified Professional in Healthcare Quality (CPHQ), or Healthcare Quality and Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment is required. Required Minimum Knowledge, Skills, Abilities and Training: * Knowledge of quality management methods, tools, and techniques and ability to create and support an environment that meets the quality goals of the organization. * Knowledge of federal, state and local healthcare related laws and regulations; ability to comply with these in healthcare practices and activities * Experience developing and implementing clinical, service and operational process improvement initiatives, both small and large scale. * Knowledge and expertise in specific performance improvement/CQI methodologies (e.g., Six Sigma, LEAN). * Current knowledge of accreditation and regulatory requirements for acute and ambulatory care services (e.g. state, federal, local regulations; Joint Commission, etc.). * Experience with the event reporting process, root cause analyses, and event investigation/review * Experience with patient compliant/grievance investigations and prompt resolution * Knowledge of the risks faced by patients in a healthcare environment, and the ability to take steps to reduce these risks * Familiar with all legal documents related to hospital liability, including management of subpoenas, Summaries and Complaints and other related activities * Knowledge of processes, tools and techniques for assessing and controlling an organization's exposure to risks of various kinds; ability to apply this knowledge appropriately to diverse situations. * Ability to manage collaboratively and coaches others to achieve optimal performance; delegate effectively; praise/rewardcontributions; define clear roles and responsibilities; set goals and lead initiatives; adjust plans as necessary * Ability to anticipate, recognize, and deal effectively with existing or potential conflicts at the individual, group, or situation level; ability to apply this understanding appropriately to diverse situations * Ability to identify opportunities and take action to build strategic relationships between one's area and other areas, teams, department, units or organizations to help achieve business goals * Strong professional, organizational and interpersonal skills for working with teams, physicians, committees and senior management * Excellent communication skills (oral and written), presentation style, including the ability to concisely present data to leaders, clinicians and staff at all levels of the organization #LI-CHI
Share this job:
