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Director of Quality

3 months ago

Jacksonville, United States UT Health Jacksonville Full time

Overview:

In a joint venture partnership with UT Health System, Ardent operates UT Health East Texas in Tyler, Texas. UT Health East Texas is comprised of UT Health Tyler (the areas only Level I trauma center), UT Health North Campus, UT Health Athens, UT Health Carthage, UT Health Henderson, UT Health Jacksonville, UT Health Pittsburg, UT Health Quitman, UT Health Air1/EMS, UT Health East Texas Rehabilitation Hospital, UT Health Long Term Acute Care, UT Health Hope Cancer Center and UT Health East Texas Physicians. With 974 licensed beds, UT Health East Texas is advancing healthcare, together.

POSITION SUMMARY

The position of Quality and Patient Safety Director at UTHET is accountable for assisting the organization to improve quality, safety, and reduce operational risk exposure through performance improvement processes and meeting regulatory and accreditation requirements. They will assist in the implementation of UTHETs Quality/Clinical effectiveness function. This position supports a culture of high reliability and the measurement of care quality identifying opportunities and executing on strategies for performance improvement in the following areas of the organization:

  • Outcomes - highly reliable processes, delivering exceptional outcomes and/or optimal health
  • Safety Deliver the safest care to patients driven through leadership and a culture of high reliability
  • Accreditation-Ensures all regulatory requirements are managed and highly functional
  • Experience of Care - relationship-centered care grounded in empathy, dignity, respect and collaboration
Responsibilities:
  • Support a proactive, comprehensive strategic Quality agenda that inspires caregiver engagement, inter-professional collaboration, the identification and use of evidence-based practice and management among all entities in the system while differentiating UTHET as a high reliability organization nationally.
    • Provides accurate and meaningful data to teams, committees and physician groups by understanding data dictionaries and using appropriately, using self-coded data sheets, assisting in determining appropriate data to collect by asking right questions and identifying correct populations, and using working knowledge of existing databases to obtain data already being collected.
  • Appropriate knowledge and application of basic statistical tools, such as, standard deviation, frequency distributions, histograms, and Pareto charts.
  • Actively participate in divisional meetings, processes, and activities to ensure Quality functions are disseminated consistently throughout the division.
  • Chair and lead the local Performance Improvement Committee.
  • Acts as a liaison between the Performance Improvement Committee and the Governing Board, to ensure all CMS CoPs are met.
  • Applies quality improvement methodologies as a quality representative/facilitator for PI Teams and as a consultant to provide basic CQI or statistical tools.
  • Evaluates and makes recommendations for system improvements using quality data, event and regulatory compliance reports.
  • Provides project management to assigned teams by providing leadership to focus areas and by utilizing facilitation and assessment skills to develop evidence-based initiatives.
  • Manage the organizations Infection Prevention and Control Program; including the establishment, implementation, and routine review of Infection Prevention and Control Policies and Protocols to support the strategic Infection Prevention and Control Plan/goals. This is accomplished by evaluating regulatory requirements/best practices and gathering pertinent business, financial, service, and other operations information.
  • Submit/receive/disseminate, in a timely manner, data and information to/from public health, regulatory organizations, NHSN, CDC, CMS, accrediting bodies, and other appropriate agencies. Participates in data analysis and performance improvement activities as outlined in the Infection Prevention and Control Plan and as requested by leadership
  • Work with the Corporate Infection Prevention and Control Council to create education related to infection prevention and control goals and objectives. Provides educational recommendations to other hospital leadership and/or hospital committees using learning principles and available educational tools and technology.
  • Communicate and educate providers and caregivers as needed to ensure understanding and compliance with infection prevention and control standards.
  • Act as a liaison to public health authorities and other representatives from the various state, federal and accrediting bodies (such as TJC, CMS, etc.), as assigned.
  • Receive annual training/education related to infection prevention and control from a recognized best practice source (ie: CDC, NHSN, APIC, etc).

Regulatory Compliance:

  • Drives all regulatory functions on the local level.
  • Applies a current working knowledge of regulatory compliance standards as appropriate to assignment or specialty.
  • Participates in all divisional regulatory functions and standards.
  • Leads the participation and management of the Internal Quality Survey process, including timely and appropriate response to action plans.
  • Lead and drive the sustainability efforts for all IQS and TJC action plans to ensure compliance is maintained and practice changes are hardwired.
  • Provides advanced consultation and support by collaborating with peers throughout the corporation to develop methods and plans to meet standards, participating in the writing or development of new policies, procedures and guidelines, researching literature and outside sources to identify new methods, technologies, or approaches for compliance, ensuring compliance to regulatory support and assessing compliance to standards to ensure a safe and consistent care environment to multiple areas and settings.

Patient Safety:

  • Leads Mission Zero: Our Culture of Safety on the local level, based on division standards and expectations.
  • Leads and/or functions as the Risk Manager on the local level, based on division standards and expectations.
  • Applies a current working knowledge of national, local, and system patient safety standards and trends as appropriate to assignment or specialty.
  • Leads PSEA and RCA efforts and reports to the Ardent PSO, per requirements.
  • Participates in the division SENT process for reporting safety events.
  • Participates in the division safety event classification process.
  • Provides collaboration and consultative support to Risk Management, Compliance, Medical Staff, Nursing, and others by compiling reports with recommendations from appropriate sources, participating in maintenance of applicable Safety Plans, networking across departments and facilities to achieve objectives and goals, participate or facilitate patient safety improvement teams, and engages and interacts with staff at all levels to encourage ownership of initiatives.

Practice Standardization and Policies:

  • Advocate and support standardization by educating focus areas to centrally developed policies, procedures, processes, and forms and assisting/participating in corporate teams with the development of policies, procedures, processes, and forms.
  • Participate in development, implementation, revision, and review of policy, procedures, protocol, guidelines, and forms, when appropriate for focus areas.

Education:

  • Provides education to focus areas regarding Quality Monitoring and Improvement, Regulatory Compliance, Patient Safety, Risk Management, Medical Staff Services and Practice Standardization and Policies.

Informatics, Data and Analytics

  • Support quality measurements for internal use.
  • Support and distribute standardized reports that are developed centrally to ensure consistency in data management and reporting across the division.
  • Support the deployment and optimization of the electronic health record to maximize safety, quality outcomes, clinical effectiveness and efficiency.
  • Advance, with others, the use of predictive analytics and deep learning computing to improve the health, experience and quality of care of those we serve.?

SUPERVISION:

Depending on the facility, the director may be responsible for 3-5 direct reports.

Qualifications:

Education & Experience

  • Required: Bachelor's degree in Business, Healthcare Administration, Public Health or other business related field. Education must be obtained through an accredited institution and will be verified.
  • Applicants must have a minimum of 6 years of hospital clinical experience or 4 years experience with quality, infection prevention, and/or performance improvement in addition to tertiary education.
  • Current certification in infection prevention (CIC) or obtains within 2 years of hiring to position.
  • Experience leading successful Quality Improvement projects.
  • Experience with change management with the ability to provide leadership in the adaptation and implementation of new processes and /or technology that enhance Quality.
  • Experience overseeing patient safety programs.
  • Experience leading teams.
  • One of the following certifications is preferred-CPHQ, CPXP, CPSP, CPHRM
  • Experience working in a complex health system (hospitals, ambulatory clinics, post-acute care, etc.)
  • Experience with external entities that drive and support Quality approaches and standards, including government agencies, academic institutions, universities and related organizations of higher education, and other public institutions is preferred

Knowledge, Skills & Abilities

  • Effective verbal, written and interpersonal communication skills.
  • Trained in improvement science (i.e., Six Sigma, Lean, UT System CSE or DMAIC)