Under the direction of the VP, Quality and Safety, the Director, Quality and Safety identifies, develops, formulates, and implements strategic goals and objectives for Luminis Health's Quality and Safety program, including regulatory readiness programs. The Director will work with hospitals, ambulatory practices, clinicians, health system leaders, and interdisciplinary teams to consistently deliver measurable improvement and provide structure to assure the achievement of quality and safety goals and regulatory compliance as a high reliability organization.
Essential Job Duties:
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions
- Participates, with other senior ambulatory and hospital personnel in the analysis, planning and strategy formulation of ambulatory and hospital entity goals and the implementation of plans and programs; analyzes operations and clinical outcomes to determine potential enhancements or improvements to processes and activities.
- Key leader in the development, monitoring and ongoing refinement of quality and safety standards across all hospital, ambulatory and medical groups of Luminis Health including office practices and extension with community partners.
- Provides support and leadership in the areas of clinical performance and process improvement, guidance and/or facilitation in response to risk, safety, and licensing requirements for the organization to create a high reliability organization.
- Leads, monitors and trends root cause analysis (RCA) and any actions resulting from root cause analysis and case reviews and reports back findings and updates.
- Manages projects to insure timely completion of reports by identifying data sources, collects data to establish quality and patient safety measures, coordinates with data analysts and tracks data specifications and facilitates meetings, bridging the analytics to clinical and operational requirements.
- Triages the urgency of safety events alerting the Vice President of Quality and Safety and operational leaders to activate resources if needed.
- Coordinates patient and environmental safety rounds with hospital and ambulatory leaders.
- Collaborates and participates in Luminis Health Quality and Safety Committees.
- Gathers data from internal and external (local, state and national) data sources to establish benchmarks/goals for Quality and Safety Indicators. Gathers information and insures application of high reliability principles learned from quality and safety initiatives throughout the country that are applicable to Luminis Health's Quality and Safety Plan.
- Develops and implements educational approaches and methods of systemic performance improvement to create and maintain LH as a high reliability organization, outlined in Luminis Health's Quality and Safety Plan.
The minimum level of education and experience for this position includes:
- Completion of formal M.S. degree in healthcare related field from an approved educational institution.
- Five to eight years in health care with increasingly complex management experience demonstrated.
- At least 3 years' experience in the provision of Quality and Safety Management.
- Personal computer literacy required.
- Experience with word processing and spreadsheet applications.
- Demonstrated understanding and implementation of continuous quality improvement methodologies in a health care setting.
- Demonstrated knowledge of federal and state regulations related to health care as well as knowledge of Joint Commission healthcare standards, CMS, NCQA, State of Maryland, and other legislative and regulatory initiatives.
- Experienced with High Reliability and Safety initiatives and has the ability to apply statistical process systems.
- Demonstrates strong interpersonal skills and relationships with all levels of hospital and medical staff and Board of Directors.
- CPHQ or CPPS certification preferred.
- Current licensure as a registered nurse by the Maryland Board of Nursing preferred.
Working Conditions, Equipment, Physical Demands:
There is a reasonable expectation that employees in this position will be exposed to blood-borne pathogens.
Physical Demands - Light Duty
The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.
The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.