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Director, Quality and Patient Safety
4 months ago
Saint Anthony Hospital is a diverse and community-centric organization your career can thrive in, while addressing the health and wellness challenges that families in our neighborhood face. Our employees deliver on our mission and achieve success by working together to provide excellent customer service and patient care. As part of Saint Anthony Hospital#s commitment to providing the highest quality health care, we will be building a new state-of-the-art hospital to serve as an anchor to the Focal Point Community Campus. Learn more at#www.focalpointchicago.org#. # Position Purpose: #The Director, Quality Resources#provides leadership for and#management of Quality/Performance Improvement, Patient Safety, Infection Prevention and Control, Patient Experience, and clinical initiatives for Sepsis and Stroke.# The Director, Quality and Patient Safety facilitates regulatory compliance activities throughout the organization and acts as a liaison between federal, state, and other accrediting bodies. Leads the development and implementation of hospital-wide## Performance Improvement activities.# Annually reviews and revises the facility Performance Improvement Plan and submits the plan to the Board of Directors for review and approval. Provides leadership and support for the management of Quality Assessment and Performance, Infection Control, Patient Experience, and external regulatory activities.# Assures effective manpower utilization, development, and performance. Participates in decisions to employ, evaluate, transfer, and, when necessary, terminate employees. Develops budget for department and ensures operations are within budget. Oversees data collection required for The Joint Commission, CMS, and other accrediting bodies. Assures timely submission of data through selected vendor.# Coordinates system preparation for The Joint Commission triennial and for cause surveys. Facilitates system compliance with external agency requirements by coordinating site visits, routing updated requirements to appropriate individuals, coordinating responses to identified deficiencies, and communicating open issues to appropriate leadership individuals. Assures education of all entities and staff within the organization on the principles, tools, and concepts to support performance improvement, patient and staff safety, and external regulatory agency compliance. Monitors trends and analyzes all performance improvement data, including medical staff peer review.# Assures reporting of all significant trends and issues to the appropriate committees and senior leadership.# Assists in the development of action plans and appropriate follow-up. Actively participate in Risk Management and Patient Safety activities related to all events that are designed as #Near Miss# or #Sentinel Events#.# Provides leadership for the development of Root Cause Analysis and develops action plans for all such events. # Qualifications: Master#s Degree Required, Registered Nurse, State of Illinois. Five to Ten years of experience with regulatory compliance activities and performance improvement initiatives. Certification/Training in Quality/Patient Safety: CPHQ, Certificate in Healthcare Quality and Patient Safety, Lean training, TeamSTEPPS Ability to work alone, concentrate, handle multiple priorities in a stressful situation, assist with problem-solving and demonstrate a high degree of patience. Ability to cope with high levels of stress, manage altercations, cope with confrontations, cope with anger/fear/hostility of others in a calm manner. Excellent customer relations and interpersonal skills. # Saint Anthony Hospital Highlights: Saint Anthony Hospital is an independent, nonprofit, faith-based, acute care, community hospital dedicated to improving the health and wellness of the families on the West Side and Southwest Side of Chicago. Saint Anthony Hospital has been certified as a Primary Stroke Center by The Joint Commission. Saint Anthony Hospital offers competitive wages and a comprehensive benefits program for employees and their families. Saint Anthony Hospital employs and teaches some of the city#s brightest, most innovative resident physicians and medical students. # EQUAL OPPORTUNITY Saint Anthony Hospital is an affirmative action/equal opportunity employer and does not discriminate in hiring or employment based on age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation, or any other protected status. #
Saint Anthony Hospital is a diverse and community-centric organization your career can thrive in, while addressing the health and wellness challenges that families in our neighborhood face. Our employees deliver on our mission and achieve success by working together to provide excellent customer service and patient care.
As part of Saint Anthony Hospital's commitment to providing the highest quality health care, we will be building a new state-of-the-art hospital to serve as an anchor to the Focal Point Community Campus. Learn more at www.focalpointchicago.org .
Position Purpose: The Director, Quality Resources provides leadership for and management of Quality/Performance Improvement, Patient Safety, Infection Prevention and Control, Patient Experience, and clinical initiatives for Sepsis and Stroke. The Director, Quality and Patient Safety facilitates regulatory compliance activities throughout the organization and acts as a liaison between federal, state, and other accrediting bodies.
* Leads the development and implementation of hospital-wide Performance Improvement activities. Annually reviews and revises the facility Performance Improvement Plan and submits the plan to the Board of Directors for review and approval.
* Provides leadership and support for the management of Quality Assessment and Performance, Infection Control, Patient Experience, and external regulatory activities.
* Assures effective manpower utilization, development, and performance. Participates in decisions to employ, evaluate, transfer, and, when necessary, terminate employees.
* Develops budget for department and ensures operations are within budget.
* Oversees data collection required for The Joint Commission, CMS, and other accrediting bodies. Assures timely submission of data through selected vendor.
* Coordinates system preparation for The Joint Commission triennial and for cause surveys.
* Facilitates system compliance with external agency requirements by coordinating site visits, routing updated requirements to appropriate individuals, coordinating responses to identified deficiencies, and communicating open issues to appropriate leadership individuals.
* Assures education of all entities and staff within the organization on the principles, tools, and concepts to support performance improvement, patient and staff safety, and external regulatory agency compliance.
* Monitors trends and analyzes all performance improvement data, including medical staff peer review. Assures reporting of all significant trends and issues to the appropriate committees and senior leadership. Assists in the development of action plans and appropriate follow-up.
* Actively participate in Risk Management and Patient Safety activities related to all events that are designed as "Near Miss" or "Sentinel Events". Provides leadership for the development of Root Cause Analysis and develops action plans for all such events.
Qualifications:
* Master's Degree Required, Registered Nurse, State of Illinois.
* Five to Ten years of experience with regulatory compliance activities and performance improvement initiatives.
* Certification/Training in Quality/Patient Safety: CPHQ, Certificate in Healthcare Quality and Patient Safety, Lean training, TeamSTEPPS
* Ability to work alone, concentrate, handle multiple priorities in a stressful situation, assist with problem-solving and demonstrate a high degree of patience.
* Ability to cope with high levels of stress, manage altercations, cope with confrontations, cope with anger/fear/hostility of others in a calm manner.
* Excellent customer relations and interpersonal skills.
Saint Anthony Hospital Highlights:
* Saint Anthony Hospital is an independent, nonprofit, faith-based, acute care, community hospital dedicated to improving the health and wellness of the families on the West Side and Southwest Side of Chicago.
* Saint Anthony Hospital has been certified as a Primary Stroke Center by The Joint Commission.
* Saint Anthony Hospital offers competitive wages and a comprehensive benefits program for employees and their families.
* Saint Anthony Hospital employs and teaches some of the city's brightest, most innovative resident physicians and medical students.
EQUAL OPPORTUNITY
Saint Anthony Hospital is an affirmative action/equal opportunity employer and does not discriminate in hiring or employment based on age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation, or any other protected status.
