JOB SUMMARY

Manages the activities of Quality & Patient Safety with responsibility for results including costs, methods, and staffing. Ensures quality department goals are achieved, timelines met, and service excellence is provided in all aspects of work. Provides subject matter expertise for hospital quality. Leads and supervises the community resources assigned to quality across inpatient and outpatient services. Leads the quality management system ensuring alignment between system goals and specific community needs. Receives assignment in the form of objectives and determines how to use resources to meet schedules and goals. In partnership with providers and quality leadership, leads the quality agenda in area of responsibility (might be communities or program), to reach top performance and outcomes. Oversees local patient safety and regulatory functions to promote patient safety and compliance with regulatory and accreditation requirements. Also partners with Infection Prevention to support infection control. Collaborates with other leaders across PeaceHealth to maintain alignment with system goals.

QUALIFICATIONS

Education

• Bachelor of Science Required.
• Master’s Degree Preferred.

Experience

• Minimum of 5 years Required: Healthcare administration or government-related healthcare administration, safety experience
• Minimum of 5 years Preferred: Quality Improvement experience
• Minimum of 2 years Preferred: Leadership experience
• Preferred: Broad knowledge of patient safety, regulatory, and quality improvement
• Preferred: Training in statistical process control methods

Credentials

• Required within 2 years: Certified Professional in Healthcare Quality

SKILLS

• Ability to deliver financial results for areas of accountability. (Preferred)
• Advanced skills in QI methodologies and tools. (Preferred)
• Ability to communicate to multiple audiences, prioritize and maintain perspective for organization’s vision and quality. (Preferred)
• Familiarity with CMS Conditions of Participation and relevant accreditation standards to fully participate in regulatory surveys. (Preferred)
• Ability to communicate to multiple audiences, prioritize and maintain perspective for organization’s vision and quality. (Preferred)
• Able to work effectively with multiple individuals/groups both internally and externally. (Preferred)
• Able to effectively engage at all levels and teams toward desired outcomes. (Preferred)
• Understanding of the use of data, data integrity and public reporting. (Preferred)
• Familiarity with research design helpful. (Preferred)
• Excellent communication skills both written and verbal. (Preferred)
• Proficient with MS Office applications. (Preferred)
• Strong facilitation and delegation skills. (Preferred)
• Demonstrated ability to prioritize among multiple competing needs. (Preferred)
• Demonstrated flexibility in working with community leaders to meet specialized needs of Critical Access Hospitals if applicable. (Preferred)
• Advanced knowledge of Patient Safety principles. (Preferred)

• Provides day to day leadership and management for staff including hiring, training, performance management, scheduling and mentoring at the facility level. Provides leadership and support for clinical improvement projects using standard tools and methodologies supported at the system level.
• May serve as co-chair for Quality Management Committee and implements the annual quality improvement plan. Monitors performance, institutes and documents improvement initiatives as needed to meet the goals.
• Supports the regulatory team by helping with regulatory readiness and accreditation surveys as needed. Provides coaching to process owners during the development of corrective action plans and audit tools. Leads unannounced surveys if the Director is unavailable or has delegated that responsibility.
• Takes responsibility for facility-specific patient safety activities and partners with patient safety consultants to identify, implement and oversee patient safety improvements, participating in patient safety reviews, to prioritize events, assist in RCA pre-work, help develop action plans and monitor effectiveness of actions. Ensures best practice standards within the health care environment are followed, guides development of clinical risk reduction initiatives and methodologies.
• Ensures the ministry has well-designed and reliable processes and systematically monitors, analyzes and improves its performance to ensure high quality patient care, outcomes and experience in a safe and cost-effective manner.
• Partners with system and local leadership to achieve system-wide strategic clinical excellence initiatives.
• Serves as content matter expert for publicly reported measures of quality (e.g. Hospital Compare, Leapfrog group), utilizing system resources as indicated.
• Assures the utilization of a lean approach using standard improvement methodologies and tools.
• May participate in the budget planning process; authorizes and/or monitors expenditures, develops and implements cost-savings procedures.
• Performs other duties as assigned.