Director Quality/Patient Safety/Risk

OPERATIONS:
A.

Determines proactive strategies and methods necessary for high performance culture related to quality, patient safety and risk management.

B.

Effectively utilizes national best practices and benchmarking sources in support of top level performance by THD for core measures and pay-for-performance metrics.

C.

Analyzes trends of events related patient safety and risk reduction issues to establish process improvements as needed.

D.

Maintains current information on national, state, regional, and local regulations that impact accreditation and compliance (Joint Commissions, CMS < American College of Surgeons, CARF)
E.

Oversees implementation of a critical events review and root cause analysis system that provides aggregated trended data for leaderships use.

F.

Supervise peer review activities in conjunction with the CMO and Medical Staff Office.

G.

Present quality data and initiatives to Medical Staff, leadership, and departments as necessary.

H.

Achieves and maintains internal and external customer satisfaction.

LEADERSHIP :
A.

Directs the activities of the organization related to Quality, Patient Safety, and Risk Management departments either directly or thru managers.

B.

Develops an annual plan including operating metrics for dashboard.

C.

Participates in appropriate THR and community forums.

D.

Skillfully achieves positive results for the organization related to investigations of complaints requiring the Director’s direct involvement.

E.

Facilitates as lead staff various organizational level meetings to include QPC, MEC, and other hospital committees in conjunction with CMO.

F.

Available for one-on-one meetings with a wide range of stakeholders for education/development and problem-solving.

G.

Provides major education offerings on new tools, techniques and approaches to a wide variety of audiences as appropriate.

H.

Represent THD with outside contingence on matters of quality.

I.

Support and facilitate the Performance Improvement Oversight Committee.

J.

Act as a designated lead for quality and risk matters in the absence of the CMO.

K.

Establish priorities for department growth and enhancement based on need, research findings, and industry trends.

L.

Collaborate with nurses providing direct patient care and members of other disciplines at all levels in the development, implementation, and evaluation of program and services

HUMAN RESOURCES:
A.

Oversees the effectiveness of the department recruitment and retention program, taking action as necessary to provide an adequate level of qualified staff.

B.

Promotes professional growth, development, and accountability in staff, students, and colleagues.

C.

Coaches and mentors staff to improve their performance and continue to develop their professional skills.

D.

Identify leadership talent and actively develop leadership skills in staff and advance them as leaders within THR.

E.

Support diversity objectives of the organization in recruiting and promoting.

F.

Achieves and maintains high levels of employee satisfaction.

FISCAL MANAGEMENT:
A.

Prepare the operating and capital budgets for the department
B.

In collaboration with the department management and staff, determine the appropriate number and level of staff, balancing competency, patient needs, patient outcomes, patient safety outcomes and productivity guidelines
C.

Manage the approved budget and adjust strategies as needed to meet budgeting expectations
D.

Regularly communicate with staff and customer groups as appropriate regarding hospital/departmental goals, results and future direction.

E.

Advocate for appropriate fiscal and Human Capital resources to accomplish work/goals for the department and the entity.

The ideal candidate will possess the following qualifications 

Education
Bachelors Degree in clinically related discipline required
Masters Degree in Business, Healthcare Administration or clinically related discipline preferred

Experience
5 years progressive management experience in healthcare field inclusive of quality, patient safety, and/or risk management required.

3 years performance improvement experience with proven accomplishments and outcomes required.

Experience in a highly reliable organization (HRO) preferred

Licenses and Certifications
Licensure as required by the State of Texas for clinical discipline required upon hire
CPHQ – Certified Professional in Healthcare Quality, or, CPHRM – Certified Professional in Healthcare Risk Management preferred upon hire.

Lean Six Sigma Belt Training preferred upon hire

Skills
Knowledge of industry standards related to Joint Commission, CMS, OSHA, regulatory standards for areas of responsibility.

Knowledge of continuous improvement tools and techniques, inclusive of contemporary models (six sigma, lean, clinical microsystems as examples).

Proven data analytics capability.

Excellent verbal/presentation and written skills with the ability to communicate effectively with a wide variety of professional and non-professional stakeholders.

Demonstrated ability to lead and direct teams as well as facilitate performance/process improvement teams.

Able to supervise a diverse and independent staff.

Self-directed and goal/outcomes/measurement driven.

Proficient computer and Microsoft Office skills.