Director Quality, Patient Safety, and Risk

#REF!•Plano, TX

1d•Onsite

About The Position

This role oversees and facilitates accreditation activities, directs and supports processes that advance patient safety and performance improvement, and oversees medical staff peer review. The position also involves developing and implementing strategies for employee relations, supervising departmental staff, and planning and executing a comprehensive quality and safety management process in collaboration with leadership. Additionally, this role assists in the investigation and response to sentinel events, near misses, complaints, and grievances, and is responsible for fiscal management including budget development and monitoring.

Requirements

Bachelor's Degree BSN Required
7 Years clinical nursing Required
5 Years progressive management experience Required
RN - Registered Nurse Upon Hire Required
Excellent verbal and written communication, negotiation and collaboration skills
Ability to collect, analyze and organize data
Team facilitation skills
Knowledge of regulatory and accreditation requirements
Ability to educate and motivate
Able to use Microsoft Office applications

Nice To Haves

Master's Degree Preferred
Managerial Experience Strongly Preferred
Quality Experience Preferred
CPHQ - Certified Professional in Healthcare Quality Upon Hire Preferred
CPHRM - Certified Professional in Healthcare Risk Management Upon Hire Preferred

Responsibilities

Oversight and facilitation of accreditation activities (TJC, Chest Pain & Stroke certifications, Bariatric certification, etc.).
Direct and support processes and coordinate tactics that advance patient safety and performance improvement.
Track, trend and monitor performance improvement outcomes and risk events.
Work with other departments on hospital and system initiatives and support evidence-based best practices.
Ensure annual completion of FMEA for the acute care and Seay Behavioral Health Center.
Direct clinical outcomes program.
Oversee and facilitate Medical Staff Peer Review, including OPPE and FPPE.
Assist peer review physicians and division chiefs in preparing and presenting case reviews and completing follow-up activities.
Develop and implement strategy to create and maintain a positive employee relations environment.
Recruit, orient and retain excellent staff.
Supervise departmental staff, developing standards of performance, evaluating performance and initiating or recommending personnel actions.
Mentor job-related growth of staff.
Plan and execute in collaboration with Chief Medical Officer, Chief Nurse Executive and Texas Health leadership the implementation of a comprehensive quality and safety management process.
Develop and maintain KPI quality dashboard.
Direct the preparation and maintenance of department reports and tracking of data for quality and safety initiatives.
Monitor and supervise hospital compliance with The Joint Commission (TJC) and governmental agencies, standards and requirements, acting as liaison during site reviews.
Participate in and represent THP in system-wide quality/patient safety committees and initiatives.
Coordinate with other departments to develop action plans for performance improvement and patient safety initiatives and risk reduction.
Conduct initial investigation of sentinel events/near misses/complaints/grievances.
Work with CQO/hospital staff/medical staff regarding management of event and communication with the patient/family.
Communicate with the patient/family as necessary.
Coordinate and facilitate RCA meetings and development of action plans.
Monitor progress and effectiveness of RCA Action Plans.
Work with Risk Manager to develop reports and results of action plans for Risk Management/Patient Safety Committee and Quality Integration Committee.
Manage complaint/grievance process.
Assist in development of capital and operational budget and monitor compliance.
Consider clinical, quality and operational outcomes and financial implications when making recommendation for changes in practices.