Director of Quality And Patient Safety

Location

Pasadena, TX | United States

Job description

Overview

Patients Medical Center (PMC) provides inpatient and outpatient medical and surgical services to residents of Pasadena, Deer Park, La Porte, Baytown, and Clear Lake. The facility includes 53 medical/surgical beds, eight ICU beds and three endoscopy rooms, and offers a range of primary and specialized services—wound care, general surgery, gastroenterology, occupational health, heart and vascular, women’s services, diagnostic imaging, outpatient rehab services, and sleep disorders.

Responsible for the design, coordination, implementation and management of the Organization’s Performance Improvement (PI) and Patient Safety plans. Identifies opportunities for improved patient care and outcomes and reductions in harm, with the implementation of evidence-based practices. Provides leadership in defining, implementing and integrating quality, safety, service and efficiency strategies into the plans, policies, and organizational processes that affect the organization’s operations and strategic direction.

Responsibilities

1. Establishes performance improvement goals annually with relevant stakeholders. Ensures the Performance Improvement and Patient Safety plans and the hospital-focused projects for the year are implemented and their effectiveness is evaluated annually. Develops and implements processes and formats which support data collection, aggregation, analysis, and action planning. Assures data is managed appropriately and disseminated to appropriate leadership staff. Provides leadership in developing quality improvement and patient safety training programs and coaches organizational clinical/service lines and operational/support departments in quality improvement principles.

2. Oversees the events reporting process, root cause analyses, investigations and requests from the claims team (including management of subpoenas, Summons and Complaints, and coordination of legal documents related to hospital liability). Participates in system office initiatives and programs to mitigate risks in the facility which have been identified at other hospitals, resulting in reduced costs, adverse patient outcomes and ultimately safer patient practices and care.

3. Collaborates with the Medical Staff and Organizational Leadership to develop and enhance safe patient care while achieving optimal outcomes, including the organization’s peer review program and ongoing and focused practitioner evaluation.

4. Provides leadership and is responsible for accreditation and regulatory survey readiness. Oversees mock survey tracers to assess survey readiness. Provides education to staff and providers on regulatory compliance. Organizes required staff to develop responses to survey deficiencies and submits responses to the appropriate accreditation or regulatory agency.

Required Experience

Minimum of five (5) years of progressive management responsibility in an acute care setting, two (2) of which is related to managing an organization’s Quality Improvement Program. Minimum of two (2) years of clinical, patient care experience or equivalent. Experience developing and implementing clinical, service and operational process improvement initiatives, both small and large scale. Knowledge and expertise in specific performance improvement/CQI methodologies (e.g., Six Sigma, LEAN). Current knowledge of accreditation and regulatory requirements for acute and ambulatory care services (e.g. state, federal, local regulations; Joint Commission, etc.).

Required Education

Bachelor's degree in a healthcare-related field or five (5) years of related job or industry experience in lieu of degree.

Required Licensure:

Certified Professional in Healthcare Quality (CPHQ), or Healthcare Quality and Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment is required.

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