Director of Quality Initiatives and Improvement (DQI)

Hackensack Meridian Health•Perth Amboy, NJ

About The Position

Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It’s also about how we support one another and how we show up for our community. Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change. The Director of Quality Initiatives and Improvement (DQI) leads all hospital-based work to eliminate preventable harm to patients, family members, and staff and to attain unsurpassed clinical and patient-reported outcomes for assigned hospital(s). Builds organization-wide participation in improvement through transparency, collaboration and mutual learning. Collaborates with leaders to achieve the Hackensack Meridian Health (HMH) quality goals and eliminate preventable harm. Facilitates the redesign of patient care processes; leads root cause analyses process, analyzes data to inform and guide improvement efforts, and develops organizational capacity for improvement through teaching and mentorship. While directing the assessment, planning, implementation, monitoring and evaluation of best practices, this position ensures that cost effective, quality care is administered to all patients in accordance with the hospital performance improvement (PI) plan, while complying with the standards of all regulatory and accrediting agencies. Provides leadership in the implementation and integration of the Department of Patient Care Performance Improvement Plan in addition to ensuring Joint Commission on Accreditation of Healthcare Organizations (JCAHO) & regulatory compliance. Oversees various activities of the Patient Safety and Quality Department while aligning with the Medical Center and HMH Performance Improvement Plan in assuring compliance with all Patient Safety Indicators, Quality Care Transition Teams & Nursing Quality. Advances the integration of the science of patient safety and continuous learning throughout the organization. Furthers the objectives of Quadruple Aim including optimizing patient throughput and Length of Stay. Oversees the Nurse Practitioner service to help achieve the goals of the pillars of Quadruple Aim.

Requirements

Master's Degree in Nursing, Health Care Administration, Public Health, other advanced health-related degree, or equivalent experience.
Minimum of 7-10 years of clinical experience in an acute care hospital.
Minimum of 3-5 years of experience in patient safety and quality.
Experience with NDNQI & Magnet Accreditation.
Proficient in the RCA-2 Process.
Strong communication and presentation skills.
Excellent written and verbal communication skills.
Proficient computer skills that include but are not limited to Microsoft Office and/or Google Suite platforms.

Nice To Haves

Performance Improvement expertise.
HRO experience.
Mastery of performance improvement methodologies.
Highly collaborative leader.

Responsibilities

Provides leadership to all safety and quality improvement activities at a hospital including committee meetings, medical staff peer review, root cause and apparent cause analyses, event management, morning safety report, follow up of ONELink event reports, and specific improvement cycles including optimization of STEMI care.
Provides leadership to local high reliability organization (HRO) transformation.
Engages all levels of leadership, caregivers and staff in advancing patient safety through HRO training, morning safety huddles, and joint event management with the departments of Human Experience and Risk Management.
Oversees the Nurse Practitioner service and ensures they are deployed in an efficient manner to further improve our quality metrics, improve throughput and LOS and support patient experience improvement efforts.
Develops and oversees organizational quality initiatives and the monitoring of quality priorities.
Presents quality data results with analysis and recommendation to a variety of organizational committees and councils including Department of Patient Care to enhance achievement of HMH quality goals.
Oversees all quality improvement staff and their work in quality councils, teams and committees.
Ensures that their team members achieve certification by the National Patient Safety Foundation as a Certified Professional in Patient Safety (CPPS), attend conferences, and receive continuing education including presentation skills, project management, process mapping, and lean principles.
Cultivates and promotes continuous learning inside and outside of the network.
Ensures compliance with all federal and state regulatory and licensing requirements, including aspects of Joint Commission readiness.
Directs root cause and apparent cause and common cause evaluation of events and follow up activities.
Identifies events, near misses and opportunities for quality and system improvement through the use of event reports, morning safety huddles, and trends identified through data analysis.
Presents risk reduction strategies and follow up at Patient Safety Council to facilitate shared learning and scalability where possible.
Identifies appropriate metrics to track meaningful change.
Guides continuous learning and transparency related to patient safety and quality initiatives- Incorporates continuous learning including evidence based best practices, scalable system improvements, safety stories with lessons learned and needs identified through claims, suits and events.
Through analysis of data, distinguish isolated events from trends and deploy resources to address those impacting patient experience, outcomes and ROI.
Engage all levels of caregivers and staff in advancing patient safety through HRO training, quality initiatives addressing small wins and when designing system improvement.
Utilize a variety of modes to increase the reach including webinar, video conferencing and interactive presentations.
Guides hospital work in achieving HMH annual and strategic quality goals.
Participates as a non-voting member in the Hospital Peer Review Committee, where applicable.
Leads initial case screening prior to submission to the committee.
Ensures use of appropriate methodologies and relevant tools to achieve rapid cycle improvement (i.e. PDSA, FMEA, reliability science, bundle science, process flows).
Collaborates with the Patient Safety and Quality Department as well as with the VP, Chief Quality/Safety to ensure that organizational wide safety and quality initiatives are implemented effectively and risk reduction strategies implemented wherever appropriate.
Ensures effective analysis of performance data with comparison over time and comparisons to internal and external benchmarks to identify improvement opportunities.
Oversees and facilitates regularly scheduled updates and educational sessions for physician and nursing leaders, managers, and team members throughout the organization so that they are able to use the monthly quality scorecard information and participate in achieving the HMH quality goals.
Ensures trend analysis is completed and appropriate response to unfavorable trends are developed and deployed.
Develops and implements action plans based on analysis of data results.
Supervises the education of staff in regards to relevant performance improvement theories and tools to staff & managers.
Communicates and educates on Joint Commission and Regulatory standards, assists with Joint Commission readiness.
Ensure plans and designs are consistent with internal and external expectations for accreditation, regulatory compliance and public reporting.
Aligns performance improvement to the Magnet philosophy.
Responsible for interviewing and hiring of patient safety and quality staff and managing performance evaluations.
Assuring all staff act in accordance with the Medical Center Code of Conduct.
Member of the Patient Safety Committee, Performance Improvement Coordinating Committee, Nurse Executive Council, Nursing Operational Committee.
In concert with the HMH VP Patient Safety and High Reliability coordinates and oversees the completion of the National AHRQ Survey on the culture of safety and the annual National Leap Frog Survey for the Medical Center.
Maintains professional growth and development through seminars, workshops and professional facilitations to maintain and extend expertise of self and team.
Other duties and/or projects as assigned.
Adheres to HMH Organizational competencies and standards of behavior.