Director Quality Patient Safety
The posted compensation range of $49.20 - $71.34 /hour is a reasonable estimate that extends from the lowest to the highest pay CommonSpirit in good faith believes it might pay for this particular job, based on the circumstances at the time of posting. CommonSpirit may ultimately pay more or less than the posted range as permitted by law.
Responsibilities
This position is responsible for the design, coordination, implementation and management of the Organization’s Performance Improvement (PI) and Patient Safety plans and 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.
Essential Key Job Responsibilities
Establishes performance improvement goals annually with relevant stakeholders. Ensures the Performance Improvement Plan 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.
Implements and oversees the organization-wide patient safety program and manages the reporting, data analysis and evaluation as outlined in the Patient Safety Plan. 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.
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.
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.
Has overall accountability for assigned work group relative to operational goals, personnel requirements, and budgetary constraints.
Qualifications
Required Education and Experience:
- Bachelor's degree in a healthcare-related field or five (5) years of related job or industry experience in lieu of a degree.
- Minimum of five (5) years of progressive management responsibility in a health care setting, two (2) of which is related to managing an acute care organization’s Quality Improvement Program.
- Minimum of two (2) years of clinical, patient care experience or equivalent.
Required Licensure and Certifications:
Current State License in a clinical field. Five (5) years’ experience in Quality Management can be used in lieu of state license.
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.
Required Minimum Knowledge, Skills, Abilities and Training:
- Knowledge of quality management methods, tools, and techniques and ability to create and support an environment that meets the quality goals of the organization.
- Knowledge of federal, state and local healthcare related laws and regulations; ability to comply with these in healthcare practices and activities
- 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.).
- Experience with the event reporting process, root cause analyses, and event investigation/review
- Experience with patient compliant/grievance investigations and prompt resolution
- Knowledge of the risks faced by patients in a healthcare environment, and the ability to take steps to reduce these risks
- Familiar with all legal documents related to hospital liability, including management of subpoenas, Summaries and Complaints and other related activities
- Knowledge of processes, tools and techniques for assessing and controlling an organization's exposure to risks of various kinds; ability to apply this knowledge appropriately to diverse situations.
- Ability to manage collaboratively and coaches others to achieve optimal performance; delegate effectively; praise/rewardcontributions; define clear roles and responsibilities; set goals and lead initiatives; adjust plans as necessary
- Ability to anticipate, recognize, and deal effectively with existing or potential conflicts at the individual, group, or situation level; ability to apply this understanding appropriately to diverse situations
- Ability to identify opportunities and take action to build strategic relationships between one’s area and other areas, teams, department, units or organizations to help achieve business goals
- Strong professional, organizational and interpersonal skills for working with teams, physicians, committees and senior management
- Excellent communication skills (oral and written), presentation style, including the ability to concisely present data to leaders, clinicians and staff at all levels of the organization
#LI-CHI
OverviewSt. Luke's Health–Sugar Land Hospital offers the latest technology and treatments for residents of Fort Bend County and Southwest Houston. Our services range from heart care and neuroscience to robotic surgery. Our recently opened Family Birthing Center offers incomparable care and amenities in a spa-like environment to provide a VIP—Very Important Pregnancy—experience. Since 2008, our experienced doctors, nurses, and support staff have provided expert care to support our community.
Unless directed by a Collective Bargaining Agreement, applications for this position will be considered on a rolling basis. CommonSpirit Health cannot anticipate the date by which a successful candidate may be identified.
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Depending on the position offered, CommonSpirit Health offers a generous benefit package, including but not limited to medical, prescription drug, dental, vision plans, life insurance, paid time off (full-time benefit eligible employees may receive a minimum of 14 paid time off days, including holidays annually), tuition reimbursement, retirement plan benefit(s) including, but not limited to, 401(k), 403(b), and other defined benefits offerings, as may be amended from time to time. For more information, please visit https://www.commonspirit.careers/benefits.
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CommonSpirit Health™ is an Equal Opportunity/Affirmative Action employer committed to a diverse and inclusive workforce. All qualified applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, marital status, parental status, ancestry, veteran status, genetic information, or any other characteristic protected by law. For more information about your EEO rights as an applicant, please click here [PDF].
CommonSpirit Health™ will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c). External hires must pass a post-offer, pre-employment background check/drug screen. Qualified applicants with an arrest and/or conviction will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, ban the box laws, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances. If you need a reasonable accommodation for any part of the employment process, please contact us by telephone at (415) 438-5575 and let us know the nature of your request. We will only respond to messages left that involve a request for a reasonable accommodation in the application process. We will accommodate the needs of any qualified candidate who requests a reasonable accommodation under the Americans with Disabilities Act (ADA). CommonSpirit Health™ participates in E-Verify.