01277 Maria Parham Health Director PI, PE PSO JOB SUMMARY Director of Performance Improvement/ Patient Experience/ Patient Safety Officer (PSO) is responsible for the overall direction, leadership and operational management of the patient safety, performance improvement and patient experience programs of Maria Parham Health. The Director will have accountability for understanding, coordinating and measuring performance of internal and external patient safety requirements and will provide leadership in strengthening a just culture where everyone is engaged and respected. Develop and implement the foundational strategy and change management that is necessary to balance growth and sustainability with the highest level of quality, safety and service, ultimately reducing variation in patient care. Direct and implement evidence-based programs, practices and activities that realize continuous improvements in patient safety, patient experience and staff engagement. Reports to: CNO FLSA: Exempt Grade: EEO: X 01 Officials and Managers □ 02 Professionals □ 03 Technicians □ 04 Sales Workers □ 05 Administrative Support Workers □ 06 Craft Workers □ 07 Operatives □ 08 Laborers and Helpers □ 09 Service Workers JOB REQUIREMENTS Minimum EducationBachelor's degree required Required SkillsCertifications:Basic Life Support (BLS) certification within 90 days of hire.CPPS certification upon hire or within twelve (12) months of hire. Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action. Minimum Work ExperienceThree (3) years of work related/project management experience. Trained in methodologies like Six Sigma, LEAN, Green belt preferred. Advanced skills with Microsoft applications including Outlook, Word, Excel, and Powerpoint. Excellent data analytics skills. ESSENTIAL FUNCTIONS 1. Perform a variety of complex and independent activities involved in the collection, analysis, documentation and interpretation of data related to departmental quality, safety management and compliance with federal and state regulations.2. Evaluate and interpret collected data and prepare written reports and analyses setting forth progress, adverse trends and appropriate recommendations or conclusions.3. Develop forms and procedures to track and compile information and apply appropriate data analysis techniques.4. Confer with the Director of Risk, Regulatory Compliance, and Privacy Officer in the design and review of reporting procedures to serve the purposes of quality assurance; determine the validity and appropriateness of quality improvement criteria and measures utilized by the department; make appropriate recommendations to the medical staff.5. Plan and conduct in service orientation and education for supervisors and employees pertaining to departmental quality assurance policies, procedures and documentation requirements.6. Stay abreast of new developments in the field of Quality Management and Patient Safety; recommend new policies and revise existing policies/procedures for compliance standards.7. Collaborates with the Hospital Support Center for external reporting requirements.8. Prepares directives, guidelines, and information on various components of a Performance Improvement Program for dissemination within the hospital.9. Oversee the Medical Staff Performance Improvement activities and coordinate with hospital wide Performance Improvement to demonstrate continuous Quality Improvement.10. Prepare and present clinical data and PI information to the Medical Staff Departments, hospital multi-disciplinary committees, Patient Safety Clinical Quality, Medical Executive Committee and Board of Trustees.11. Assists with the investigation and review of sentinel events and near miss occurrences and performs root cause analysis. Collaborates with medical staff, administration and other hospital personnel regarding disclosure of medical errors.12. Prepares and guides directors, managers, and frontline staff to assess quality compliance and PI in their individual areas, to identify areas for improvement.13. Assist administration with medical staff development, quality, credentialing, and peer review activities, as indicated.14. Provides oversight and management for the patient complaint and grievance process through incident/occurrence reporting.15. Ability to perform medical record review for the purpose of identification of real or potential risk and the monitoring of documentation practices.16. Participates in the Environment of Care committee and safety surveillance rounds as indicated. Collaborates with the Hospital Safety Officer to identify and reduce risks in the environment.17. Coordinates with the Chief Executive Officer, Chief Nursing Officer and Chief Finance Officer concerning administrative adjustments to patient accounts in response to patient are concerns or in response to an occurrence.18. Communicates the mission, vision and goals of the facility.19. Completes in-services and annual mandatory training in a timely manner.20. Completes probationary and annual evaluations of staff in timely manner.21. Complies with organizational policies regarding ethical business practices.22. May be required from time to time to perform other periodic or occasional assignments/duties/responsibilities, work overtime, other shifts, and/or varied schedules as requested. NONESSENTIAL FUNCTIONS Add locally FUNCTIONAL DEMANDS Populations Served□ Does not treat or care for patients.□ Neonate (<30 days)□ Infant (<1 year)□ Early Childhood (1 year and <5 years)□ Late Childhood (5 years and <13 years)□ Adolescent (13 and <17 years)□ Young Adult (17 to <30 years)□ Middle Adult (30 years to <60 years)□ Older Adult (>60 years) Protected Health InformationType of Protected Information Accessed:□ Demographic□ Clinical□ Insurance□ Financial□ Complete Medical Record Bloodborne Pathogens ExposureWhile performing this job, occupational exposure is present for all employees Physical Requirements - Physical Dexterity and Effort: Rarely <1%, Occasionally 1-33%, Frequently 34-66%, Constantly 67-100%Bending/Stooping □ rarely, X occasionally, □ frequently, □ constantlyClimbing X rarely, □ occasionally, □ frequently, □ constantlyKeyboard Data Entry □ rarely, □ occasionally, X frequently, □ constantlyKneeling X rarely, □ occasionally, □ frequently, □ constantlyLifting/Moving Patients □ rarely, X occasionally, □ frequently, □ constantlyReaching X rarely, □ occasionally, □ frequently, □ constantlyRepetitive Foot/Leg Movements X rarely, □ occasionally, □ frequently, □ constantlyRepetitive Hand/Arm Movements □ rarely, □ occasionally, X frequently, □ constantlyRunning X rarely, □ occasionally, □ frequently, □ constantlySitting □ rarely, □ occasionally, X frequently, □ constantlySquatting X rarely, □ occasionally, □ frequently, □ constantlyStanding □ rarely, X occasionally, □ frequently, □ constantlyWalking □ rarely, X occasionally, □ frequently, □ constantlyPushing / Pulling: 0-25 lbs. □ rarely, X occasionally, □ frequently, □ constantlyPushing / Pulling: 26-75 lbs. X rarely, □ occasionally, □ frequently, □ constantlyPushing/Pulling: over 75 lbs. X rarely, □ occasionally, □ frequently, □ constantlyLifting/Carrying (non-patient) : 0-25 lbs. □ rarely, X occasionally, □ frequently, □ constantlyLifting/Carrying (non-patient) : 26-75 lbs. X rarely, □ occasionally, □ frequently, □ constantlyLifting/Carrying (non-patient) : over 75 lbs. X rarely, □ occasionally, □ frequently, □ constantly Visual Acuity, Hearing and Speaking: Rarely <1%, Occasionally 1-33%, Frequently 34-66%, Constantly 67-100%Audible Speech □ rarely, □ occasionally, X frequently, □ constantlyHearing Acuity □ rarely, □ occasionally, X frequently, □ constantlySmelling Acuity X rarely, □ occasionally, □ frequently, □ constantlyTaste Discrimination X rarely, □ occasionally, □ frequently, □ constantlyVision: Depth Perception □ rarely, □ occasionally, X frequently, □ constantlyVision: Distinguish Color □ rarely, □ occasionally, X frequently, □ constantlyVision: Seeing Far □ rarely, □ occasionally, X frequently, □ constantlyVision: Seeing Near □ rarely, □ occasionally, X frequently, □ constantly Biological: Rarely <1%, Occasionally 1-33%, Frequently 34-66%, Constantly 67-100%Biohazardous waste/ hazards □ rarely, X occasionally, □ frequently, □ constantlyBlood and/or bodily fluids □ rarely, X occasionally, □ frequently, □ constantlyCommunicable diseases/pathogens □ rarely, X occasionally, □ frequently, □ constantly Chemical: Rarely <1%, Occasionally 1-33%, Frequently 34-66%, Constantly 67-100%Asbestos or lead X rarely, □ occasionally, □ frequently, □ constantlyCytotoxic Chemicals X rarely, □ occasionally, □ frequently, □ constantlyDust X rarely, □ occasionally, □ frequently, □ constantlyHazardous Chemicals X rarely, □ occasionally, □ frequently, □ constantlyGases/Vapors/Fumes X rarely, □ occasionally, □ frequently, □ constantlyHazardous Medication X rarely, □ occasionally, □ frequently, □ constantlyLatex □ rarely, □ occasionally, X frequently, □ constantly ORGANIZATIONAL EXPECTATIONS Maria Parham Health is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual’s age, color, disability, genetic information, gender, gender identity, national origin, race, religion, sexual orientation, or veteran status. **Job:** **Quality* **Organization:** ** **Title:** *Director of Quality & Patient Safety Officer* **Location:** *NC-Henderson* **Requisition ID:** *7460-9336*