System Director Quality, Safety & Clinical Risk

Description

POSITION SUMMARY

The System Director for Quality, Safety and Clinical Risk is responsible for the direction and leadership of operational, financial, programmatic, and employee related activities. This includes establishing, meeting and continuously monitoring the goals and objectives while maintaining alignment with the strategic goals and objectives of Oneida Health. The Director works closely in collaboration with the Compliance Officer, Chief Nursing Officer and Chief Medical Officer to develop policies and programs for risk mitigation, infection prevention, and to ensure all accreditation and regulatory requirements are met. This position involves significant interdepartmental collaboration and knowledge of electronic health records and other data systems. The employee interprets regulatory and accreditation standards, reports on data obtained related to these standards, and conducts educational programs for hospital employees and members of the medical staff. The work is performed under the general direction of the Chief Nursing Officer.

KEY RESPONSIBILITIES

• Oversee Oneida Health’s Risk Management program, including development and oversight of the annual risk management work plans.
• Assist the medical, nursing and professional staff in developing criteria by which problem areas can be identified, assessed and resolved.
• Develop an annual quality assurance plan and prepares methods for continued assessment or evaluation on the effectiveness of current quality assurance activities.
• Prepare and distribute reports on results of quality assurance activities which will include recommendations to resolve identified problems.
• Act as consultant to medical staff and clinical teams in developing criteria for prioritizing identified problems, risk management strategies, and best clinical practices for patient safety.
• Maintain continuity in the analysis of activities, documentation of information and data, follow-up activities to improve the quality of care and completion of reporting functions.
• Collaborate closely with Facilities leadership to ensure a safe and compliant environment of care including, but not limited to compliance with OSHA standards, CMS and state regulations, and Joint Commission standards.
• Attend all medical staff committee and other departmental and committee meetings affecting quality assurance problems and activities affecting the monitoring and resolution of identified problems.
• Review and integrate quality assurance plans prepared for and used in various departments across the system to eliminate duplication of effort, improve communications and reduce costs.
• Follow up on all activities performed in compliance with quality assurance plans and make recommendations or perform corrective action.
• Oversee the investigation and management of all significant adverse events and conduct Root Cause Analyses as indicated.
• Remain abreast of and ensure compliance with risk-related state and federal regulatory standards.
• Coordinate Board Quality Assurance Committee.
• Oversee the Patient Experience program.

MANAGEMENT OF PERSONNEL AND LEADERSHIP

• • Collaborate with key stakeholders to develop and implement a Quality Strategic Plan, including opportunities for growth, new technologies, delivery system opportunities, and operational improvements across the care continuum. 
  • Hire, direct, coach and monitor the performance of all direct reports to develop and maintain high-performance teams that meet organizational and departmental goals. Remove barriers and enable teams to succeed in a highly dynamic and growing health care environment.
  • Engage and implement effective team building, trust, development, creative problem-solving and conflict resolution processes.
  • Address performance issues promptly and appropriately and use sound judgment in compliance with policy, applicable laws and regulations.
  • Monitor and ensure all direct reports are current with compliance and safety requirements. Implement and manage all organizational safety directives and goals.
  • Role model, lead and influence the organizational design and effectiveness of the Quality, Safety and Clinical Risk operational model to promote interdisciplinary collaboration and shared accountability while continually improving the experience of patients, providers, and staff.
  • Effectively facilitate meetings at the department and organizational level.
  • Articulate and present data, information, and ideas in a clear and concise manner.
  • Communicate with medical staff, department leaders, senior leaders, and board members to maintain coordination across the system.
  • Ensure integration of ethical standards and core values into everyday work activities.

MANAGEMENT OF RESOURCES

• • Responsible for budget development, regular monitoring, accountability and meeting all operational targets for all areas within span of control.
  • Adjust systems as necessary to meet budget and/or productivity targets for cost-effective quality care.
  • Support a decentralized management philosophy (Shared Governance) across the care continuum by designing and supporting a system that facilitates employee involvement at the unit/clinic, Department, and Oneida Health level.

EDUCATION/OUTREACH

• • Actively participate in development of policies, procedures, education and best practice.
  • Foster strong working relationships with all levels of the organization to facility effective communication and to connect to staff’s daily priorities to the organization’s strategic goals.
  • Maintain membership in professional organizations to develop knowledge and resources through networking, continuing education, and participation in national, regional, and/or local activities.

RESEARCH/BEST PRACTICE

• • Evaluate current research for applicability within units/ programs of care.
  • Ensure results of quality assurance studies are used to identify and design process improvement projects.
  • Monitor and report key performance indicators across the system.
  • Remain current of new trends and best practices and incorporate into practices and programs.
  • Develop and implement clinical outcome measures for quality improvement, cost and complication reduction, and implementation of evidence-based practices.

Qualifications

EDUCATION: Bachelor’s degree (required); Master’s degree (preferred); Licensed clinicians, other than nurses, will be considered commensurate with education, knowledge, skills and acquired experience.

EXPERIENCE: Minimum of five (5) years of relevant experience in quality, patient safety, compliance, risk management, or performance improvement. Minimum of three (3) years of progressive leadership experience. Knowledge/ experience in Lean Six Sigma, PDSA or other performance improvement methods. Current regulatory, accreditation experience.

LICENSES & CERTIFICATION: Unencumbered Registered Nurse (RN) license in State of New York (required); Certification in specialty (preferred).

 REQUIRED SKILLS, KNOWLEDGE & ABILITIES:

• Managerial skills necessary to plan, organize, and direct operational activities
• Strong organizational and negotiation skills that are conceptual as well as practical
• Demonstrated interpersonal skills necessary to interact with all levels of hospital personnel and external parties
• Strong clinical knowledge of best clinical practices
• Comfort with an interdisciplinary culture of collaboration, particularly partnering with key stakeholders to achieve goals.
• A passion for excellence, which elevated the abilities and competencies of the various patient care providers
• Excellent verbal and written communication skills with meticulous attention to detail

AGE SPECIFIC COMPETENCY: Patients served by direct or indirect patient care – Infants (Birth-11months); Adolescent (13-19yrs); Young Adult (20-40yrs); Middle Adult (41-65yrs); Older Adult (>65yrs)

Salary : $110,000 - $148,000