Director of Quality & Patient Safety, Mount Auburn Hospital

Beth Israel Lahey Health•Cambridge, MA

1d•$130,000 - $159,994•Onsite

About The Position

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives. Reporting to the Chief Medical Officer, responsible for the oversight, leadership and direction of the healthcare quality and patient safety programs for Mount Auburn Hospital and Mount Auburn Professional Services’ (MAPS) ambulatory practices. Serves as an organizational leader in design, development, implementation and monitoring of quality and safety initiatives, plans, metrics and goals. Leads change by using continuous performance improvement methods to support ongoing regulatory readiness, improved quality outcomes, reducing preventable harm and improving patient and caregiver experience. The Director of Quality & Patient Safety acts as an expert resource across the organization overseeing complex projects to completion through team facilitation and team building. This role collaborates with leaders and staff, and is a role model and in high reliability, just culture, change management theory, and regulatory standards. Interacts with the Board of Trustees to support committee meetings. The Director actively leads interventions that reinforce and support a culture of safety and high reliability. This role collaborates with leaders across the organization Root Cause Analysis (RCA), Failure Mode Effects Analysis (FMEA) and other quality and safety tools that support a journey to achieving zero patient harm. Responsible for data submission to clinical indicator and quality measurement systems and internal and external benchmark databases. Manages direct reports (quality data analysts, Quality and Safety Nurse Specialists and patient relations specialists)

Requirements

Bachelor of Science in Nursing or equivalent clinical experience required.
Minimum 5 years supervisory or management experience required.
Must possess a working knowledge of healthcare quality and patient safety management, data sets and databases, benchmarking, outcome measurement, team development.
Experience in statistical analysis and current quality improvement tools/methods. Facility in using Microsoft Excel required
Current knowledge of CMS, DPH and MassHealth hospital quality reporting requirements
Experience with database, spreadsheets and statistical process control charts.
Ability to demonstrate sound critical thinking/decision-making and ability to function well under pressure. Strong analytical ability and statistical knowledge.
Strong interpersonal, oral and written communication skills.
Proficiency with Microsoft Office including PowerPoint, Project and SharePoint required.

Nice To Haves

Master’s degree in Nursing, Health Care related field, or Hospital Administration preferred.
Certification preferred in CPHQ, CPPS or other nationally recognized quality and/or safety certification program.
rL6 Safety Reporting and Epic EHR and project management tools preferred
An equivalent combination of education and experience, which provides proficiency in the areas of responsibility listed above, may be substituted for the above education and experience requirements

Responsibilities

Initiates, oversees, and integrates a comprehensive clinical patient safety program as a component of the hospitals' quality services to improve safety of patients, visitors and employees
Acts as key resource in Quality and Safety leadership, and works closely with clinical, medical and administrative leadership to promote system wide applications of patient safety, and quality improvement strategies
Coordinates the organization’s safety event reporting program.
Provides leadership to individuals and interdisciplinary teams assure oversight of process and outcome measures, and collaborates with the Director of Regulatory Affairs and Performance Improvement on the reporting of clinical quality measures to Joint Commission, CMS and MassHealth to meet regulatory requirements.
Coordinates and oversees data collection and analysis, public reporting, measure validation processes, pay for performance initiatives, annual Leapfrog survey, US News and others.
Collaborates with the Director of Performance Improvement and Regulatory Affairs to co-lead external agency surveys, e.g. TJC, DPH, CMS
Acts as a liaison with the Massachusetts Coalition for Prevention of Medical Errors, Institute for Healthcare Improvement and the Institute for Safe Medication Practices.
Responsible for the management and supervision of the Quality Data Analysts, Patient Relations Specialists and QS RN specialists
Assumes accountability for determining, developing and evaluating annual budget.
May perform other job related duties as requested or required