Sr Director of Quality/Patient Safety

Nashville General Hospital•Nashville, TN

4d•Onsite

About The Position

Nashville General Hospital is hiring a Full Time Sr Director of Quality/Patient Safety for Quality Assurance in Nashville, Tennessee. Shift: Day Shift Primary Duties and Responsibilities Patient Safety & High-Reliability Operations • Oversee hospital-wide patient safety programs, including:  Event reporting systems  Root Cause Analyses (RCA)  Failure Mode and Effects Analysis (FMEA)  Serious safety event management  Promote Just Culture principles and psychological safety for staff.  Lead efforts to reduce hospital-acquired conditions (HACs), preventable readmissions, and adverse events.  Ensure timely follow-up, corrective action planning, and sustainability of safety improvements Quality & Regulatory Readiness: • Implement, maintain, and evaluate a comprehensive Quality and Patient Safety program that oversees care delivery performance and outcomes. • Serve as the primary point of contact for The Joint Commission, CMS, CDC, and Leapfrog; coordinate all accreditation standards, surveys, and reporting in collaboration with leaders. • Lead clinical risk management investigations, incident report analysis, and serve as a lead investigator for Root Cause Analysis (RCA) and Failure Mode and Effects Analysis (FMEA). • Oversee the integration of infection prevention and contamination control principles across all hospital units. Clinical Excellence & Professional Development: • Direct an integrated program for clinical excellence, incorporating Lean Six Sigma, Change Management, and Project Management methodologies into staff development. • Oversee the peer review program and Ongoing Professional Practice Evaluation (OPPE) support in conjunction with physician leadership to ensure medical staff competency and high-quality care. • QI support with GME programs, leading and responsible for Patient Resident Safety • Transfer and implement High Reliability Organization (HRO) principles, behaviors, and tools across the organization to foster a culture of safety and excellence. • Link clinical outcomes and patient satisfaction data to targeted professional development initiatives to address identified performance gaps. Data Analysis and Reporting • Oversee the collection, validation, analysis, and interpretation of quality and patient safety data. • Identify trends, disparities, and opportunities for improvement. • Present quality and safety performance reports to executive leadership, medical staff committees, and the Board of Trustees Experience This senior executive position requires a minimum of 10 years of progressive healthcare leadership experience. This must include at least 3 to 5 years in a senior leadership role (e.g., Senior Director or Director) within an acute care hospital with ambulatory settings, with a preference for experience in an Essential Hospital or a similar complex healthcare setting. The ideal candidate will have a proven track record in the design, development, and implementation of Quality, Incident Management, and Patient Safety programs. They must demonstrate success in improving clinical quality and patient experience outcomes by utilizing Lean Six Sigma and High Reliability Organization (HRO) principles. Experience in a teaching hospital or academic medical center, particularly in collaborating with Medical Staff Services and physician leadership for peer review and OPPE support, is highly preferred About Nashville General Hospital Nashville General Hospital (NGH) is Nashville’s original community- based hospital. Joint Commission accredited, NGH readily accommodates a wide range of needs from emergency services and acute care to ancillary and ambulatory services. NGH continues to maintain its strong commitment to the healthcare needs of Nashville and Davidson County underserved, while also providing care to all segments of the community.

Requirements

Bachelor level of Nursing
Active RN Licensure required.
Master’s degree in Nursing (MSN), Healthcare Administration (MHA), Business Administration (MBA), Quality and Safety (MHA) or a related field
Two of the following certifications (or equivalent) CPHQ, CPSO, CQMS, CLSSB at the time hire or obtained within 12 months of hired date (Candidates with a nursing or other clinical license will be given special consideration)
A minimum of (3) years of experience in the role of Director, Senior Director, or comparable, at an acute care hospital, preferably at an “Essential Hospital” or hospital operating in a similar capacity.
A minimum of (3) years of direct experience in the design, development and implementation of Quality/Incident Management/Lean/Patient Safety/Patient Experience/HRO.
Knowledgeable of Joint Commission, CMS, CDC, and Leapfrog standards and demonstrated proficiency navigating the assessment and survey processes to achieve desirable and sustainable outcomes.
Strong practitioner of LSS, Quality Management System, assessment and analysis, risk and error reduction, human factors, etc. tools and techniques.
Must be able to link and make relevant care/services outcomes to patient satisfaction, financial, and other NGH goals.
Title of Certification / License: Active TN nursing license. BLS certified. ACLS required within 30 days of hire.

Nice To Haves

Doctorate in Nursing Practice (DNP), Doctor of Healthcare Administration (DHA), or related field (Ph.D.).
This senior executive position requires a minimum of 10 years of progressive healthcare leadership experience. This must include at least 3 to 5 years in a senior leadership role (e.g., Senior Director or Director) within an acute care hospital with ambulatory settings, with a preference for experience in an Essential Hospital or a similar complex healthcare setting.
The ideal candidate will have a proven track record in the design, development, and implementation of Quality, Incident Management, and Patient Safety programs. They must demonstrate success in improving clinical quality and patient experience outcomes by utilizing Lean Six Sigma and High Reliability Organization (HRO) principles.
Experience in a teaching hospital or academic medical center, particularly in collaborating with Medical Staff Services and physician leadership for peer review and OPPE support, is highly preferred

Responsibilities

Oversee hospital-wide patient safety programs
Promote Just Culture principles and psychological safety for staff.
Lead efforts to reduce hospital-acquired conditions (HACs), preventable readmissions, and adverse events.
Ensure timely follow-up, corrective action planning, and sustainability of safety improvements
Implement, maintain, and evaluate a comprehensive Quality and Patient Safety program that oversees care delivery performance and outcomes.
Serve as the primary point of contact for The Joint Commission, CMS, CDC, and Leapfrog; coordinate all accreditation standards, surveys, and reporting in collaboration with leaders.
Lead clinical risk management investigations, incident report analysis, and serve as a lead investigator for Root Cause Analysis (RCA) and Failure Mode and Effects Analysis (FMEA).
Oversee the integration of infection prevention and contamination control principles across all hospital units.
Direct an integrated program for clinical excellence, incorporating Lean Six Sigma, Change Management, and Project Management methodologies into staff development.
Oversee the peer review program and Ongoing Professional Practice Evaluation (OPPE) support in conjunction with physician leadership to ensure medical staff competency and high-quality care.
QI support with GME programs, leading and responsible for Patient Resident Safety
Transfer and implement High Reliability Organization (HRO) principles, behaviors, and tools across the organization to foster a culture of safety and excellence.
Link clinical outcomes and patient satisfaction data to targeted professional development initiatives to address identified performance gaps.
Oversee the collection, validation, analysis, and interpretation of quality and patient safety data.
Identify trends, disparities, and opportunities for improvement.
Present quality and safety performance reports to executive leadership, medical staff committees, and the Board of Trustees

Benefits

Medical, Dental, and Vision Insurance within first 31 days of employment
Programs to reduce share of deductible and total out-of-pocket expenses
Metro Health Incentive Program - Access to high quality healthcare without incurring out-of-pocket expenses (see NGH providers without co-pays)
Short and Long-Term Disability - up to 60% of eligible weekly pay
Life Insurance - Metro provides you with basic life and AD&D coverage equal to $50,000 ($32,500 if you are age 65 or older), at no cost to you.
Retirement Plan - eligible up to IRS max limits and includes company contribution
Shift and Weekend Differential Pay Offered on Nights and Weekends
Tuition Reimbursement for employee and dependents
12 paid holidays - any holiday worked is another holiday banked
Flexible Spending Accounts
Onsite Gym
Free Parking for all employees