Director Quality and Patient Safety

The Director of Quality and Patient Safety (QPS) leads the development of a comprehensive and unified program of clinical quality, performance improvement, and patient safety in a challenging value-based healthcare delivery system. The Director works to sustain a culture of quality and safety, transparency, teamwork, measurement and accountability with clinicians and medical center team members. S/he works closely with the other AHS QPS Directors as well as the medical centers’ senior management, physician and nursing leadership, service line directors, infection prevention, Advisory Board members, and patients to instill continuous positive change in the organization’s quality and patient safety culture.

Job Responsibilities along with a percentage of time performing duties

• (30%) Quality Management Responsible for successful implementation of AHS quality and patient safety program within assigned medical center. Participates in the development and implementation of policies, programs and initiatives in order to improve the overall quality of patient care services. Partners with CMO’s, CNO’s, Department Chairs, Service Line Leaders, infection prevention, clinical staff and leadership to develop an efficient, intellectually rigorous, and engaging structure to encourage the alignment of their practice with the quality and safety agenda. Coordinate Quality Improvement Committee with assigned medical center and participates in system-wide and medical center committees.

• (20%) Process Improvement Provides oversight, support and/or consultative services (project design, selection of data required, development of documentation tools, etc. to quality improvement teams. Collaborates with the medical, nursing and other clinical leadership at the medical center to achieve excellence in metrics used by external rating organizations (CMS, Leapfrog, US News and World Report, Healthgrades, Vizient) Participates in the implementation of CMS bundle programs and other like-programs at the medical center to ensure success.

• (30%) Patient Safety: Leads the integration of high reliability organization (HRO) principles into the organization and supports the advancement of the organization and system in the HRO journey. Supports initiatives to improve the Culture of Safety including “Just Culture”. Collaborates with Legal/Risk Management to track and trend adverse events, conduct root cause analysis (RCAs) reviews, ensure the development and timely execution of complete and through risk mitigation strategies. Proactively identifies opportunities to eliminate risk using Failure Mode Effects Analysis (FMEA) and other proactive risk assessments.

• (20%) Regulatory Compliance: Establishes and implements systems and processes to ensure ongoing adherence to regulatory standards within assigned medical center. Maintains knowledge of Joint Commission, NJ Department of Health, and CMS clinical regulatory standards. Leads and coordinates all Joint Commission medical center accreditation surveys.

Supervisory Responsibilities

Provides direct supervision of the medical center Quality and Patient Safety (QPS) department team and collaborates with the AHS Infection Prevent Director in the oversight of the infection

prevention department. Implements processes to support the ongoing competency and development of the QPS team members.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the required job qualifications. Reasonable accommodations. Reasonable accommodations may be made to enable individuals and with disabilities to perform the essential functions.

Minimum Education and/or Experience Requirements

▪ Bachelor’s degree required (Nursing or health related field required)

▪ Master’s degree in a healthcare-related field or MBA

▪ 5 years’ experience in quality improvement or patient safety within a healthcare setting

▪ 3 years’ experience in leadership in a complex healthcare delivery system

▪ 3-5 years of clinical experience within an acute care hospital or health system

Required Licenses, Certifications and/or Registrations

▪ Certified Professional in Healthcare Quality or Patient Safety (CPHQ) or (CPPS)

▪ Current NJ Registered Nurse Licensure or Clinical Licensure (preferred)

Other Desired Skills, Abilities, and Knowledge

▪ Proficient in the use of all Microsoft Office Applications

▪ Excellent written and verbal communication skills

▪ Strong organization skills and ability to multi-task various responsibilities

▪ Strong data analytic skills