Corporate Director of Quality and Patient Safety- Full Time Days

Cape Fear Valley Health

2d•Onsite

About The Position

Assist with design and developing the scope of Cape Fear Health System's Quality and Patient Safety Program. Facilitate and ensure the systematic evaluation of medical services in accordance with predetermined standards. Serve as a resource person for all Medical Center Departments and as a liaison between the Medical Center and the Medical Staff. Responsible for Safety Programs throughout the health system, including obtaining and maintaining disease/Specialty specific accreditations. Perform duties and responsibilities in a manner consistent with the mission and vision of Cape Fear Valley Health System.

Requirements

Bachelor’s degree required
3 years’ experience in leading Quality programs/departments required
Proficiency in reading, writing, and speaking the English language
Knowledge of The Joint Commission Standards and Continuous Quality Improvement methodologies
Ability to analyze, interpret, and present meaningful data reports for departmental and clinical review
Strong leadership, creativity, solid knowledge base in hospital operations and organizational development, financial analysis, patient safety and process improvement
Results-oriented, excellent presentation and writing skills, keen analytical and project management skills
Must maintain a high level of confidentiality
Possess tact and diplomacy when interacting with physicians and staff
Exceptional listening, verbal, and written communication skills
Proficiency in Microsoft Office (Word, Excel, PowerPoint)
Ability to move throughout the Medical Center
Visual acuity for reviewing data and reports, observing process flows
Audiological acuity for monitoring group discussions and interactions
Verbal ability is required to effectively express ideas and views to staff
No anticipated occupational exposures to bloodborne pathogens or body fluids

Nice To Haves

BSN preferred
Certification in Six Sigma/Lean, CPHQ, CQM, CQA preferred
10 years of professional experience in quality preferred
1 year experience in hospital quality and safety preferred

Responsibilities

Design, develop and implement an effective Quality and Patient Safety Program within the guidelines of the approved Quality and Patient Safety Improvement Plan and the Joint Commission Standards
Review Quality and Patient Safety Improvement Plan and programs with the Quality Management Board
Coordinate all performance improvement activities within Cape Fear Valley Health System to maintain proper communication, focus on existing or potential opportunities for improvement and prevent duplication of events among all phases of performance improvement activities
Collect and review quarterly quality improvement reports and prepare summary for the Board of Trustees
Communicate and facilitate the integration of Performance Improvement activities of the Medical Center, Medical Staff, and other departments
Ensure the Medical Center complies with outside regulatory agency standards as they relate to Performance Improvement activities and keep abreast of all changes and recommendations relating to The Joint Commission
Maintain all information in a manner which ensures confidentiality and establish organized systems for data retention and retrieval
Coordinate and/or provide staff development programs relating to Performance Improvement
Actively participate in professional groups, such as the NCAHQP and NAHQP
Serve on Medical Center committees as appropriate
Provide leadership within the senior nursing team to support patient/family centered care delivery and transformation of the nursing culture to consistently accountable, staff nurse lead, evidence based proactive environment
Provide leadership in the implementation of robust nursing quality program
Evaluate all aspects of the current quality and safety program and implement improvements to support a state of the art, comprehensive program
Serve as an expert resource and provide ongoing education related to quality principles, systems, methods, tools, standards, adult processes data management reporting and improvement systems
Provide leadership to health system disease specific certification initiatives, including Stroke, Hip and Knee, CHF, Acute MI, and others as determined
Other duties as assigned