Director of Quality

2 weeks ago

Louisville, United States UofL Health Full time

Job Summary

This role will drive safety innovation through the identification and deployment of Patient Safety activities and work with an interdisciplinary team of Suburban Hospital leaders to achieve organizational goals related to Patient Safety. Provides education, ensures loop closure, prepares reports, presents outcomes and participates in organizational-wide continuous improvement projects as it relates to Performance Improvement, Peer Review and Patient Safety program.

Responsibilities

1. Develop, operationalize, maintain, and evaluate the Patient Safety, Clinical Performance Improvement, and Peer Review Program.
2. Provides a comprehensive assessment of organizational needs to identify strategies to improve patient safety and clinical outcomes and serves as a leader in the on-going advancement of a “Just Culture” that promotes the non-punitive reporting of patient safety concerns.
3. Develops and assists others in developing action plans for process improvement and ensures follow through and loop closure on these plans.
4. Works in collaboration with the Physician Chairs, Nursing Directors, Executive Director Quality, CMO, CQO and Quality Steering Committee and any others to evaluate the effectiveness and appropriateness of care and development of policies and procedures.
5. Facilitates identification and documentation of hospital-based approved performance improvement variances and complications.
6. Serves as administrator of designated patient safety system. This will include training, managing the event database, and participating in all educational activities as required.
7. Leads the investigation of all sentinel incidents (to include performing a root cause analysis).
8. Analyzes Vizient and other program identified mortality and complications data on a regular basis to identify areas for improvement, education, and safety improvement activities.
9. Develops and coordinates of projects that will enhance the Performance Improvement, Peer Review, and Patient Safety Program.
10. Lead multi-disciplinary projects related to the hospital’s overall goal to become a 5-star Vizient organization
11. Develops ongoing physician practice evaluation triggers.
12. Generates annual report information regarding activities and prepares statistical data.
13. Participates in patient safety-related research by providing data to investigators in compliance with HIPPA and ULH IRB regulations.
14. Keeps informed of the Joint Commission requirements for triennial accreditation standards for Performance Improvement and OPPE/FPPE standards
15. Completes case reviews and analyses for contributing factors to the variance in care and/or complications including all Serious Safety Events, deaths and complications.
16. Supports the Medical Staff departments in identifying and selecting opportunities for improvement and facilitates continuous performance improvement.
17. Facilitates Medical Staff Peer Review meetings and serves as a liaison between various committees to facilitate communication and referral of cases for further physician review, and report results back to referring committee.
18. Facilitates the creation of physician-department Performance Improvement Committees and assists in preparing case reviews and projects for discussions
19. Attend safety huddle to report any safety trends found in chart review.
20. Participate in Joint Commission survey activities as a PI and Peer Review expert to support ongoing Joint Commission accreditation.
21. Performs other duties as assigned

Qualifications

Education / Accreditation / Licensure (required & preferred):
• Bachelor of Science Degree in Nursing required, Master of Science in Nursing or other healthcare related master’s degree preferred. Certification in specialty preferred.


Experience (required and preferred):
• Minimum five (5) years of acute care, hospital-based clinical experience in area of intended practice
• Previous experience in academic teaching hospital preferred

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