Director, Quality & Patient Safety

Description

JOB SUMMARY:

• The Director of Quality and Patient Safety (DQPS) is responsible for providing the oversight, direction, coordination and integration of quality and patient safety at the entity level.
• The DQPS is responsible for contributing to and executing the strategic planning for the entity/hospital to achieve the Emory Healthcare vision by partnering with entity executives, directors and department leaders in continuously improving clinical outcomes and reducing risk.
• The DQPS is responsible for the entity¿s effectiveness and efficiency of infection control/prevention, regulatory accreditation/certification, patient safety, medical staff quality, clinical quality analytics and data reporting, and process improvement.
• The DQPS collaborates with system program directors to standardize these functions across Emory Healthcare.
• Leadership Functions Supports the entity's performance improvement program and patient safety culture by positioning the Quality and Patient Safety Department to be a critical and central element to strategic planning, program development, collaboration and change management under the Emory Healthcare Strategic Roadmap.
• In conjunction with Emory Healthcare Office of Quality and Risk (OQR) and entity executives, sets short and long term goals for quality improvement, patient safety, and pro-active improvement of processes.
• Provides direction for the Quality and Patient Safety Department in support of the achievement of departmental and organization goals and objectives.
• Leads collaborative partnerships among all entity departments to support patient centered, safe and effective care.
• Provides regular updates to entity leadership on reportable events, results of RCAs, accreditation readiness and survey schedules, quality metrics, and special projects.
• Responsible for position management including interview, hiring/firing, onboarding, evaluation, coaching, mentoring, training, professional development, employee recognition, etc. to maintain an active, engaged workforce.
• Collaborates with the system OQR Corporate Director of Quality Operations in all aspects of budgeting, purchases and payroll (time and attendance).
• Supports the VP-Quality in prioritizing system-wide quality initiatives.
• Contributes to annual quality and patient safety reports.
• Ensures timely internal reports and communication to entity leadership and system leadership.
• Represents Quality at New Leader Orientation and New Employee Orientation at entity level.
• Leads T2 Quality huddle and presents at T3 Hospital (or T4 PGP) huddle as well as at the System Quality huddle, coaches employees in Lean Operating System and standard work, actively rounds in the department and across the entity
• Serves the entity on the following committees/meetings: Infection Prevention Steering Committee RAPC (Risk Assessment and Prevention Committee) OQE Staff meeting Entity Patient Safety Committee Entity Peer Review Committee Entity Medical Executive Committee EHC Leader Meeting Entity-specific process improvement governance committees Entity Mortality Reviews
• Additional entity-specific committees as needed Process Improvement: Facilitates the use of statistical process tools, process improvement and problem solving through Lean methodology for continuous improvement in all care and services provided at the entity.
• Oversees the integration of performance improvement processes with medical staff leadership to review and improve overall patient care outcomes and the peer review process.
• In collaboration with Emory Healthcare System Leadership, creates and executes an effective
• Performance Improvement program at the entity.
• Develops, implements and monitors the PI Plan.
• Completes annual review of the PI plan and revises the plan as needed to meet organizational goals and regulatory compliance.
• Oversees LEAN activities at the entity level which impact quality and patient safety.
• Participates in all system-wide PI initiatives.
• Patient Safety: Leads the strategic initiatives and facilitates proactive risk reduction/patient safety activities and follow-up on all near misses and/or untoward patient care outcomes.
• Collaborates with entity executives and Patient Safety Officer to develop, implement and monitor the patient safety plan with an annual review and appropriate revisions to meet organizational goals and regulatory compliance.
• Oversees the event reporting system at entity level to ensure report capture, tracking, analysis and reporting occurs at entity.
• Provides education on patient safety strategies, human factors and high reliability concepts.
• Oversees Failure Mode Effect Analysis and/or Root Cause Analysis or other activities in response to events; monitors action plans for sustainability.
• Responsible for the entity Patient Safety Committee.
• Collaborates with entity leaders, medical staff and risk management to respond to sentinel events, medical disclosures, etc.
• Collaborates with system and entity leadership regarding reporting of sentinel events to appropriate regulatory agencies.
• Participates in all system-wide patient safety initiatives.
• Regulatory Requirements / Accreditation / Certifications: Responsible for internal and external reporting based on federal, state and other regulatory requirements including sentinel events and notifying entity and system leadership of all reporting.
• Coordinates continued survey readiness for entity accreditation/certification, onsite survey response and required follow up.
• In collaboration with Program Director for Accreditation and Certification, coordinates and executes the Accreditation/Certification Readiness program for State, CMS and TJC at the entity. Develops, implements and monitors accreditation readiness activities.
• Implements activities to respond to new or revised regulations or standards from the State, CMS or TJC.
• Utilizes tracer software to review activities to ensure ongoing compliance with existing regulations and standards; shares results of tracers with entity leadership for action planning and monitoring.
• Provides education throughout entity regarding appropriate accreditation readiness topics to ensure all leaders, medical staff, volunteers, stakeholders, etc. are prepared to respond to on site surveys.
• Trains entity leaders to conduct tracers utilizing AMP software.
• Serves as the entity¿s Administrator for the TJC website.
• Serves as coordinator and liaison for on-site State, CMS and TJC surveys.
• Collaborates with entity leaders to create response(s) to CMS and TJC for on-site survey RFIs, complaint investigations, etc.
• Leads the entity's Accreditation Readiness Committee. Participates in all system-wide accreditation readiness initiative
• Oversees institution certifications (Stroke, Bariatric, etc) as defined by entity leadership Infection Prevention: Coordinates infection control and prevention activities of the entity in accordance with the infection prevention plan.
• In collaboration with the Program Director for Infection Prevention and Control, coordinates and executes the Infection Prevention program at the entity and standardizes processes in surveillance, data collection, validation and reporting.
• Oversees Root Cause Analysis on hospital acquired infections.
• Participates in developing the annual entity risk assessment.
• Collaborates with system IP to annually review and revise the Infection Prevention & Control Plan as appropriate.
• Participates in the system Infection Prevention Steering Committee and entity Infection Prevention & Control Committee.
• Oversees infection prevention and control assessment and improvements for the entityÂ's environment of care.
• Collaborates with entity and system leadership for a thorough investigation and reporting of an outbreak of disease.
• Participates in all system-wide infection prevention initiatives.
• Data Reporting and Analysis: Oversees the entity's data collection analysis and reporting processes related to performance improvement, patient safety, and risk reduction to the Board, MEC, Administration, Management and all appropriate staff to facilitate improvements and safety of all key processes.
• Develops systems to collect, measure, and report performance improvement results.
• In collaboration with the Program Director for Performance Analytics, coordinates and develops metrics to drive improvement of care and processes at the entity.
• Works with department leaders and the medical staff to identify meaningful metrics to improve processes and care.
• Collaborates with the system data analytics team for data collection, reporting and submission to regulatory bodies: CMS and TJC.
• Collaborates with system data analytics team on any validation data sent to external sources i.e. TJC, GHA, QHIP, CMS, NHSN, NSQIP and other registries if applicable.
• In collaboration with entity executives and medical staff leaders, manages the organization's peer review functions, including OPPE/FPPE.
• Organizes mortality reviews and implements process improvements.
• Participates in system-wide data analytics initiatives.
• Other duties as assigned. (This position reports to the VP-Quality with dotted line responsibility to the entity via the CQO.)

MINIMUM QUALIFICATIONS:

• Masters degree from an accredited college or university in Nursing, Public Health, Healthcare Administration, Industrial and Systems Engineering, or other quality related field.
• (In lieu of a Masters degree, candidates with 10 years leadership experience in healthcare quality and accreditation may be considered).
• Seven years of experience in healthcare quality & accreditation including three years leadership experience.
• Must hold Six-Sigma and/or Lean certification and/or experience and attain CPHQ within 2 years of employment.