Job Description

Position Summary:
Reporting to the Chief Medical Officer of the local hospital, and working in partnership with the System Quality and Safety Department, the Director of Quality and Patient Safety (DQPS) will support the development and implementation of a comprehensive quality and patient safety program at a Steward Health Care System hospital. In collaboration with system and local clinical and administrative leadership, the DQPS, will support leadership, education and project management at their local hospital in accordance with the quality and safety plan of the Steward Healthcare System. The goal is to improve quality, operational clinical initiatives, promote innovation and to identify/develop best practices for clinical excellence, service excellence and patient safety. The DQPS will oversee hospital specific operations inclusive of hospital performance improvement, infection control, risk management, patient care assessment activity, patient advocacy, patient safety, regulatory affairs and service excellence in partnership with other hospital leaders to promote model programs and approaches in assuring superior deliver of services. Serves as a clinical consultant for the model of local implementation for quality improvement and patient safety.
Key Reponsibilities:
The DQPS will provide leadership in the design, development, implementation, and evaluation of clinical quality improvement activities that create the infrastructure that delivers high quality and safe care. The DQPS will directly oversee a dynamic team of quality professionals including Risk Managers, Infection Control Practitioners, Patient Advocates, and Performance Improvement Analysts. The DQPS will establish and maintain a standardized and ongoing program for regulatory readiness that promotes continual improvement in compliance related to CMS Conditions of Participation, State Hospital Licensing Rules and Regulations, and accreditation programs for CMS deemed status. Specifically, the DQPS will be responsible for ensuring accreditation/licensure through The Joint Commission, MA Department of Public Health, MA Department of Mental Health, College of American Pathologists, and others. Establishes and standardizes processes for hospital survey readiness including, 1) preparation, 2) audits, tools, and evaluation of compliance, and 3) post-survey reporting and monitoring. Performs patient safety and regulatory compliance rounding to identify patient safety risks. Empowers and educates staff to identify and participate in the resolution of patient safety events. The DQPS will identify opportunities for continuous quality improvement activities while developing a culture that perceives safety to be of paramount importance. Support the clinical leadership in each hospital to operationalize a common outcomes measurement and reporting system related to patient safety, and provide leadership in analyzing, prioritizing, implementing, collaborating, and communicating patient safety initiatives consistent with the Steward Healthcare Quality and Safety Plan. The DQPS will facilitate thorough and credible failure mode effect analysis to identify and mitigate unintended adverse patient outcomes and evaluate effectiveness of process changes. The DQPS will be responsible for preparing monthly summary reports and analysis to local senior leadership. The DQPS will also be responsible for developing and maintaining the department budget consistent with the local hospital and system financial goals. Other duties as assigned.
Required Knowledge & Skills:
• Highly motivational communication skills accompanied by the ability to analyze and present data to influence behavior, stimulate innovation, promote best practices, and drive organizational change.
• Excellent presentation style, including the ability to present data to clinicians and staff at all levels of the organization.
• A highly skilled change agent with demonstrable sensitivity to the interpersonal, group dynamic, organizational, political, and perceptual issues associated with change.
• Results orientation accompanied by the skill set required to conceptualize, implement, and operationalize a user-friendly clinical excellence and patient safety program.
• Demonstrated ability to create and sustain momentum through relationship building, and collaborative management.
• Must have experience leading and/or participating in risk identification and performance improvement activities including: Root Cause Analyses (RCA), Apparent Cause Analyses (ACA), and Failure Mode Effect Analyses (FMEA).
BS required / MS preferred in a healthcare field
5-10 years experience in a senior clinical leader position with a strong foundation in quality and patient safety.
RN preferred

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