Dir Org Quality & Patient Safety

SUMMARY
The position serves as a highly visible, champion of quality and patient safety throughout Munson Healthcare and in the assigned region and in the communities in that region.

Oversees and directs leadership of regional and system-wide efforts on quality and patient safety for the region to ensure optimal performance on nationally standardized metrics of quality and patient safety.

ENTRY REQUIREMENTS

Bachelor’s degree in health related field with relevant healthcare experience required. Master’s degree in a health related field preferred. Licensed RN preferred.

A minimum of five years of leadership experience within a health care delivery system with an in- depth understanding of regulatory requirements and health care operation.

Demonstrated experience with performance improvement methodologies and data analytic .

Demonstrated ability to work effectively at all levels within the organization including the Boards, Medical Staffs, Presidents, and Senior Leadership Teams (SLTs).

Strong critical thinking and problem solving skills.

Strong interpersonal skills that support central communication with external regulatory agencies and the individual member organization teams. Extensive knowledge/experience with The Joint Commission regulations and surveys, and compliance with the same.

Must be able to adapt to frequently changing work priorities.

ORGANIZATION

The position is under the direct and general supervision of the Chief Quality and Safety Officer of Munson Healthcare and works closely with the President of the South Region, as well as the Chief Medical Officers, Chief Operating Officers and Chief Nursing Officers of the South Region.

Develops and maintains collaborative and consistent working relationships with leaders of all clinical and support departments involved with inpatient and outpatient services, as well as the Medical Staff and their office staffs.

Has significant working contact with senior leadership teams, providers, hospital staff, leaders and general public.

AGE OF PATIENTS SERVED

Cares for patients in the age category(s) checked below:

X No clinical contact with patients

SPECIFIC DUTIES
1. Supports the mission, vision, values and principles of Munson Healthcare.

2. Embraces and supports the Munson Alignment framework.

3. Provides the leadership and vision that advances True North performance and MHC strategic goals.

4. Champion and be accountable for quality and patient safety efforts throughout Munson Healthcare and in the community.

5. Provides leadership for system-wide efforts to continuously improve the patient safety, effectiveness, efficiency, patient-centeredness, equity, and timeliness of health care delivery to all patients.

6. Leads the system to achieve outstanding performance on key, nationally standardized metrics of quality and patient safety.

7. Plays a key role in developing a comprehensive program to minimize patient harm through the implementation of systems that: create a culture of patient safety; proactively identify risk; encourage adverse event reporting and thoughtful, learning-oriented analysis of safety events and near misses; facilitate system-wide learning on the part of leaders, clinicians, trainees, and staff; and facilitate system and individual improvements required for the safest possible health care.

8. Reports quality improvement/patient safety activities to SLTs, Board Quality and Munson Healthcare Board.

9. Provides organizational leadership and strategic direction for patient safety and emergency preparedness. Ensures that the National Patient Safety Goals are implemented and measured.

10. Ensures constant state of readiness/compliance for all regulatory agencies, including the Joint Commission, CMS, and State of Michigan. Serves as the main contact and facilitator to the Joint Commission and CMS Core Measure Vendor.

11. Serves as member of BCBSM Statewide Coalition. Ensures that BCBSM PHA (Participation Hospital Agreement) Quality and Pay for Performance requirements are implemented and completed.

12. Serves as the CMS Quality Net Exchange Administrator, contact for the state quality information organization (MPRO) and acts as MCAD representative for system wide quality activities.

13. Manages, coordinates and prioritizes the work of RN Quality Specialists, Care Managers, Social Workers, and Patient Safety staff.

14. Develops departmental goals and objectives, incorporating the priorities set forth in Munson Healthcare’s strategic plan.

15. Manages departmental and human and capital resources including adherence to hospital and department policies.

16. Ensures competency requirements are met by all employees.

17. Assists with annual budgets for Quality departments and monitors appropriate utilization of budgeted resources.

18. Assists with oversight for compliance with infection prevention best practice standards and regulatory agency requirements. Works closely with Infection Prevention.

19. Performs other duties and responsibilities as assigned.