JOB SUMMARY:
Directs and monitors the operations of the Carroll Hospital's Quality & Patient Safety Department to ensure quality patient care. Responsible for facilitating the overall success of Carroll Hospital through the development and implementation of an organization-wide Quality and Patient Safety plan demonstrating a focus on prevention of harm and a reduction in adverse events. Provides expertise and guidance to Carroll Hospital leaders, physicians, managers, and staff in safe and effective system design and process improvement. Works with other leaders to ensure timely and consistent quality data measurement is available for comparison with appropriate benchmarks to support patient safety and quality related improvement initiatives and financial incentives. Reports to the VP of Quality, LifeBridge Health. 

Essential Functions: 

• Plans, organizes, directs and supervises the Performance Improvement/Quality Department, patient safety and physician peer review activities including core measure abstraction, submission and improvement; eCQM validation and compliance; FPPE; OPPE; Quality Based Reimbursement; culture of safety evaluation and improvement; Leapfrog reporting and improvement.
• Shares information about the organization’s initiatives and efforts to ensure effective operations, effective work relationships, and informed and engaged associates.
• Effectively manages the financial performance of the department in accordance with the strategic plan, mission, goals and values of the organization.
• Designs, implements, and monitors the organizational quality and patient safety plan with at least annual evaluation and revision, as needed. 
• Provides leadership and direction in assuring ongoing compliance with quality and patient safety related accreditation and regulatory requirements such as CMS, Joint Commission, COMAR, and the HSCRC.
• Oversees and manages the performance of and ongoing need for the following contracts, to include but not limited to: Q-Centrix, MACPAQ, Press Ganey, American Heart Association GWTG-CAD Registry, American College of Cardiology Foundation – NCDR CathPCI Registry and GWTG-Stroke Registry.
• Leads/Facilitates or supervises a variety of multidisciplinary teams in goal setting and accomplishment activities including but not limited to: FMEA teams, Quality Steering, Quality Council, Emergent Care, Surviving Sepsis, Safer Pain Management, MHAC Review; and various collaboratives through Premier, MPSC, etc.
• Serves as a resource to hospital and medical staff providing guidance and education on data collection, data analysis tools and techniques, and various problem-solving methodologies.

QUALIFICATIONS AND REQUIREMENTS:

• Bachelor's degree required, preferably in allied health study or other relevant field. 
• 3-5 years 
• Certified Professional in Healthcare Quality (CPHQ) is preferred