Director of Patient Safety and Quality
Job description
Nestled in the San Pedro River Valley 75 miles southeast of Tucson, Sierra Vista serves as the main commercial, cultural, and recreational hub of Cochise County and offers spectacular mountain views and year-round temperate climate. Outdoor sightseeing and recreational activities are abundant in the area with a variety of state parks, championship golf courses, tennis courts, and over 20 miles of multi-use paths within the city.
Position Summary/Description:
The Patient Safety and Quality works collaboratively with the senior leadership team, department directors, and medical staff to lead, develop and oversee a best-in-class hospital quality and safety program and to ensure regulatory compliance and accreditation.
Job Duties
Leadership
- Participate in hospital activities as a member of the leadership team.
- Role model for compliant behavior consistent with the mission, vision, and values of LifePoint and the hospital.
- Oversee the direct operations of the Quality Department, including Risk, Infection Prevention, Patient Satisfaction and Trauma Coordination.
- Motivate, mentor, develop and evaluate staff in the Quality Department.
- Promotes a culture of safety, high-reliability, patient and staff engagement, and performance excellence.
- Regularly communicate quality, performance improvement, regulatory compliance and safety activities to the medical staff, executive team, hospital leaders and Board of Trustees
- Lead the development of hospital policies and procedures related to quality improvement and patient safety.
- Develop long-range goals, annual objectives and strategies for areas of responsibility.
- Aid in the organization and implementation of the hospital and Board safety and quality committees and key strategic patient safety and quality initiatives
Quality Assurance and Performance Improvement
- In collaboration with hospital leadership, medical staff, and the Hospital Service Center (HSC) participate in the development, monitoring, reporting and improvement of activities related to hospital quality and safety in order to achieve organizational targets and goals.
- Collaborate with hospital and physician leaders to envision, develop, and implement the organization’s comprehensive safety and quality program.
- Oversees reporting and communication of quality improvement initiatives, quality and patient safety awareness, safety culture survey administration, and recognition programs. (Including reports for Medical Staff Committees, Board of Trustees, MOR, etc)
- Participates in root cause analyses and failure modes and effects analyses and debriefings.
- Takes a lead role in the LeapFrog Survey, Culture of Safety Survey, and implementation/monitoring of the National Quality Program.
- Ensures timely submission of Quality data to the HSC, LeapFrog, Quality Net, HIIN, NHSN, National Quality Program and other required agencies.
- Advanced Process Improvement Knowledge and Experience
Regulatory Readiness
- Directs and coordinates accreditation strategies to ensure compliance with State, Joint Commission and Medicare Conditions of Participation.
- In collaboration with Compliance, Risk Management, and Legal, oversee the investigation and reporting of events as required by regulatory agencies and serves as a physician liaison in PI efforts related to medical safety.
- Coordinate and oversee data collection and analysis, reporting, improvement activities and follow-up related to serious safety events via the Patient Safety Organization.
- Devise, implement and coordinate a plan for JC tracer activities.
Position Requirements:
Complies with legal, hospital and departmental policies, procedures and position requirements. Must have an active RN License (AZ within 60 days of hire). Must have an associate degree in Nursing, bachelor degree preferred.
$10,000.00 Sign On Bonus and relocation assistance with a minimum two years experience in Leadership in Quality. Two year commitment is required. Former CVMC employees who left within one year not eligible for sign on bonus and relocation***
Experience
Required
- 5 year(s): Hospital Experience
Education
Required- Bachelors or better
- Masters or better
Licenses & Certifications
Preferred- Registered Nurse
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)
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