Director, Quality & Patient Safety

Job Requirements

Company Description

When you come to the University of Maryland St. Joseph Medical Center, you’re coming to more than simply a beautiful 37-acre, 218-bed suburban Baltimore, Maryland campus. You’re embarking on a professional journey that encourages opportunities, values a team atmosphere, and makes convenience and flexibility a priority. Joining our team of healthcare professionals means you’ll be contributing to a locally and nationally recognized institution. UM St. Joseph has been recognized by The Leapfrog Group as a grade ‘A’ hospital and by U.S. News & World Report as #3 in both the state and Baltimore Metro area, making UM St. Joseph the highest-ranking community hospital in Maryland. In addition, we’ve been consistently recognized as a top employer by Baltimore magazine.

Job Summary: The Director of Quality & Patient Safety is responsible for the development, implementation and evaluation of all medical quality and performance improvement activities. The Director also provides leadership and direction to promote a culture quality throughout the organization, partnering with medical staff to strategize performance improvement programs, develop action plans and timelines for success.

Job Responsibilities and Accountabilities: *FACILITATES PAY-FOR-PERFORMANCE INITIATIVES.: Prepares the organization for quality and performance reviews. Establishes continuous, focused monitoring activities to assess efficacy of programs.

• LEADS THE DESIGN AND IMPLEMENTATION OF QUALITY IMPROVEMENT *PROGRAMS.
  
  

Supports administration, Medical Staff and department directors in carrying out activities identified in the organization's quality and performance improvement plan in order to meet the goals set forth by UMSJMC, UMMS, Maryland Department of Health Services CMS and TJC. This includes initiatives to improve Core Measures, Patient Safety Goals, MHAC HCAHPS scores and promote the journey to high reliability. Monitors progress against the plan and provides recommendations. Provides leadership to the Quality Committee of the Board. Serves on a variety of local and system committees in support of Quality Improvement as appropriate. Implements and maintains performance measure systems (i.e. ORYX and Core Measures) and directs the PI efforts to ensure that the Medical Center meets or exceeds State regulations, CMS and TJC requirements. Drives the departmental effort to become a data-driven, evidence-based practice organization in order to improve the quality of data input, data processing and data reporting. Fully engages with the UMSJMC Value Delivery System in driving quality and the goal of zero patient harm. Serves as the Leapfrog coordinator for annual submission process.

• ORGANIZATIONAL PREPARATION: Provides leadership to the Quality and Patient Safety Committee. Works with risk management to understand trends and mitigate harm. Develops, implements and oversees the Quality Management program description, Annual QM work plan. Provides leadership to support the daily patient safety huddle and other safety initiatives. *PROVIDES OPERATIONAL LEADERSHIP TO THE QUALITY MANAGEMENT*DEPARTMENT.: Recruits, hires, retains and mentors a staff of qualified professionals in support of policies, procedures and practices in accordance with stated corporate objectives and federal, state and local laws and regulations. Directs staff in the performance of Job Description Page 5 of 4 their duties, establishing work priorities and in achieving management initiatives. Provides timely and ongoing performance feedback to team-members. Works collaboratively and supports efforts of team members. Streamlines business processes to maximize efficiency and effectiveness of the department. Develops annual budget and assures fiscal
  
  

responsibility.

PROVIDES SUPPORT TO THE MEDICAL STAFF IMPROVEMENT ACTIVITIES.: Partners with Medical Staff Administration and providers to ensure coordination of the Ongoing Provider Performance Evaluations (OPPE) activities. . Establishes continuous, focused monitoring activities to assess efficacy of programs, to detect adverse health outcomes and to identify complaint patterns. Develop action plans, timelines for success and responsible persons to remedy adverse results.

• PROVIDES REGULATORY OVERSIGHT: Supports all continual accreditation readiness activities in addition to serving as an organizational resource. Provides oversight for all onsite announced & unannounced CMS and TJC surveys.
  
  

Work Experience

Education: * Master's Degree: Public health, nursing, healthcare administration or related field (Preferred) * Proven leadership experience required *Combination of relevant education and experience may be considered in lieu of degree. *Demonstrated experience with Lean Six Sigma and process redesign is preferred. *Working knowledge of principles and techniques of effective management, including training and evaluation.

Certification / Licensure / Registration: *CPHQ Certification (Preferred) *State Registered Nurse License (Preferred)

Experience and Skills: *4 – 6 years Demonstrated skills in the areas of project planning, resource allocation and status tracking and reporting (Required) *4 – 6 years Operational and/or clinical management experience within an acute care facility (Required) *4 – 6 years Significant work in healthcare quality and performance improvement (Required) *4 – 6 years Strong knowledge of the use of a variety of data collection tools (Required) *4 – 6 years Working knowledge of the National Committee for Quality Assurance (NCQA) and Quality Improvement (QI) standards (Required)

Pay Range: $60.76 - $74.62 - $97.01