Executive Director, Quality & Safety

Wellstar Health System•Roswell, GA

74d

About The Position

The Executive Director of Quality and Safety is responsible for developing a vision and executable plan to attain world class quality and safety processes and procedures across the hospital and all hospital outpatient departments (HOD) and including any associated Health Parks. Accountable to ensure successful development and deployment of the WellStar Quality and Safety strategy in a manner that supports achievement of WellStar Quality goals. Bringing patient safety and clinical quality expertise, he/she will partner with leadership, staff and system partners to identify opportunities for short and long-term impact on quality and safety outcomes in alignment with WellStar's strategic plan. Plans, organizes and directs all services and operations of the department which includes quality performance improvement, continuous survey readiness, and infection prevention programs for the hospital. Works collaboratively with hospital Vice Presidents, Directors and Managers, as well as system leadership and peers to align department goals with Hospital and System strategic goals. Oversees daily operations to ensure delivery of high quality services and support and execution of tactics designed to meet the goals. Is responsible for coordinating activities of Quality Committees with appropriate personnel, including medical staff Quality, PI and peer review committees. Ensures processes in support of accurate and high performing publicly reported quality data, WellStar quality goals and applicable data registries. Leads hospital implementation and ongoing support of Lean PI methodology. Serves as an influential champion for the WellStar Safety First program, supporting a fair and just culture of safety, accountability and organizational learning. Works to effectively integrate functions and coordinate collaboration across the care continuum. Partners with external organizations to ensure regulatory and accreditation standards compliance and to infuse best practices into improvement efforts. The individual in this role will proactively identify opportunities to optimize performance, build internal competencies, foster a strong and empowered team, and create a rigorous approach to quality and safety throughout the organization, with a strong focus on the patient, accountability and appropriate use of resources.

Requirements

Masters Public Health or Masters Health Administration or Masters Business Administration/Management or Masters Nursing or Masters Other
CPHQ - Cert Prof Healthcare Quality
RN Reg Nurse (Single State) Upon Hire
Minimum 5 years of progressive experience in healthcare quality services or support required
Minimum 5 years experience in managing a team directly required OR Minimum 5 years of experience with significant project or functional leadership within quality services required
Previous experience with proven leadership in regulatory and accreditation survey readiness, quality improvement and patient safety in a large acute care system or facility required, including demonstrated ability in interpreting quality metrics to lead actionable change required
Strong experience with patient safety event management, including conducting root cause analysis and facilitating creation of effective, timely action plans required
Experience leading improvement work using a scientific methodology required
Strong interpersonal skills with the ability to communicate and work with all levels of healthcare providers including physicians.
Ability to perform duties and responsibilities promptly and consistently with little direct supervision.
Ability to execute a plan and use project management methodology.
Ability to plan and direct activities of others and provide feedback regarding outcomes or performance.
Ability to work collaboratively with other departments within and outside the Hospital.
Ability to judge the appropriate action in response to changes, circumstances, or problems.
Experience in data collection, analysis and project management required.
Strong computer skills required.
Excellent communication, presentation and organization skills required.
Working knowledge of data collection methodologies, interpretation/analysis and decision support databases.
Exposure to workflow in event management systems with the ability to interpret and utilize trended event data to improve safety.

Nice To Haves

RN-COMPACT RN Multi-State Compact Upon Hire Preferred
Lean management system and Lean Production System methodology preferred
Experience coordinating with and reporting data to a Patient Safety Organization (PSO) preferred
Experience managing and/or monitoring infection prevention functions preferred

Responsibilities

Establishes, Oversees, and Executes the Quality and Reliability Program, including Patient Safety: Provide centralized direction, governance and leadership for major projects and programs related to Quality Performance and Patient Safety.
Develop and implement the long-term and short-term strategy for Safety and Quality.
Ensure governance level Quality reports and communications support the Board of Trustee and delegated Board committees to meet the fiduciary responsibilities.
Meet all regulatory & accreditation requirements with respect to periodic quality and safety related reports
Serve as liaison to all local level business units and entities for oversight and advising on quality improvement projects and their alignment with system goals.
Responsible for managing quality improvement and infection control for the hospital and associated Health Parks.
Committee/Work Group Support: Chair and participate in quality committees coordinated/facilitated by the department, including Quality Review Committee, Infection Control Committee, Value Committee, Medication Safety, and/or Peer Review Committees.
Integrate other appropriate improvement and High Reliability strategies and tools.
Provide advisory coaching and educational training on process improvement projects, methodology, tools, and standards.
Mitigates medical/legal liability through development of a program which links risk management activities with those of continuous performance improvement.
Contributes to the management of the accreditation, regulation, and licensing activities to include communicating the programs/processes to providers and medical staff, preparing of surveys and inspections, and completing assessments, response plans and measures of success.
Safety Event Management Program Investigation of Alleged Quality of Care Incidents: Investigate quality of care incidents and near misses according to the department's established process flows for investigating the following categories of events.
Collaborates with system and facility leadership to identify and foster reporting of all levels of safety events.
Oversees and facilitates reliable safety event classifications and identification of Wellstar reportable safety events.
Oversees safety event reporting and documentation in the electronic event reporting system, including identification of safety event trends and cause analysis processes, tracks, and trends progress.
Oversees and conducts cause analysis training.
Oversees root and apparent cause analyses processes for Wellstar reportable events; fosters identification of reliable root causes, action plans, measures of success, and shared learning across the system.
Takes action to improve as appropriate.
Infection Control Management Program Contributes to the provision of high-quality patient care by supporting infection prevention and control practices and compliance with requirements of regulatory agencies.
Participates in the identification, prevention, and control of infections by performance of surveillance activities by data collection, analysis, and reporting data.
Investigates Infection Control problems and infectious disease outbreaks.
Identify responses to improve patient care systems and mitigate risk.
Training/Surveys: Responsible for coordination Quality and Patient Safety training, including the use of Simulation/ Conduct, periodic Environment of Care survey in collaboration with other subject matter experts.
Participate in annual mock accreditation survey.
May support Failure Mode and Effects Analysis for newly internalized services.
Human Resources Management Processes: Responsible for evaluating staff performance and development.
Develops, monitors, and controls department budgets.
Makes recommendations regarding the need for staff, space, and other resources.
Performs other duties as assigned
Complies with all Wellstar Health System policies, standards of work, and code of conduct.