Summary:

The TMH Director of Quality and Safety reports to the Lifespan Vice President of Quality & Safety with dotted line engagement with hospital CMO/CNO. Under general supervision and within Lifespan established policies and procedures develops directs coordinates and evaluates the comprehensive care transformation activities leading to core measure performance physician peer review and professional practice evaluation processes as well as addressing and investigating patient safety events and working to implement corrective actions as necessary to enhance the culture of safety. The director will have administrative oversight for the development and implementation of the hospital�s quality patient safety patient experience and performance improvement programs.

The Director will lead hospital and Lifespan leadership in building outstanding educational and improvement initiatives drawing on best practices and rapid-cycle improvement techniques monitoring and interpreting performance metrics and supporting patient safety compliance and accreditation efforts. The Director will also foster and oversee the development of best-in-class customer service and patient experience initiatives by collaborating with the Director of Human Experience. The TMH Director of Quality & Safety will coordinate and align all core quality functions with the LCS strategy for quality and operational excellence and support the quality committee structure at the hospital. Provides strategic leadership and oversight for the development implementation and evaluation of quality metrics for TMH and their associated processes to achieve optimal outcomes compliance with evidenced-based care and identifies need for improvement when necessary.

 

Responsibilities:

The director leads a highly skilled team of quality and patient experience specialists focused on meeting customer needs and exceeding their expectations. Oversees and reviews selected quality issues and provides guidance for staff to lead investigations of critical events. Assists with clinical root cause/FMEA team projects using methodologies and tools utilized at Lifespan and facilitates development of corrective action plans when indicated; and oversight and monitoring as appropriate. Provides feedback reports to staff members and leadership. Assists and supports the development of reports submitted to regulatory and accrediting agencies including the Department of Health the Joint Commission others. Interfaces within the Care Transformation Quality and Safety department as needed and with other quality initiatives and committees as requested and necessary across Lifespan. Directs the effective utilization of resources (e.g. people financial material equipment) to meet established goals and objectives. Establishes departmental priorities to ensure activities support established organizational priorities and strategies.

Oversees and reviews selected quality and service issues and provides guidance for staff to initiate improvement efforts for optimized performance. Provides feedback reports to staff members and leadership. Assists and supports the development of reports submitted to regulatory and accrediting agencies including the Department of Health the Joint Commission and others. Interfaces within the Lifespan Care Transformation Quality and Safety department as needed and with other quality initiatives and committees as requested and necessary across Lifespan. Directs the effective utilization of resources (e.g. people financial material equipment) to meet established goals and objectives. Establishes departmental priorities to ensure activities support established organizational priorities and strategies.

 

Provides oversight for document peer review activity in required tracking systems. Facilitates Medical Staff and system departmental performance improvement activities as needed. Participates in Medical Staff department meetings and serves as resource for the dissemination of information related to internal and external peer review requirements.

Serves as a liaison to Lifespan Medical staff departments for coordination of quality improvement actions involving patient care processes and physician processes. Promotes meaningful communication and performance improvement information among and between Lifespan and the Medical Staff.

Provides leadership to site and/or system-wide improvement teams using various performance improvement methodologies. Manages clinical and patient safety data needs and leads team(s) toward implementing successful improvement strategies.

Monitors overall performance metrics for diagnostic populations as assigned and for communicating with internal and external customers related to monitoring clinical patient safety and operational performance metrics as requested. Responsible for achieving improved performance in all areas of core measure and reported/monitored metrics.

 

Works with hospital leaders to develop measure analyze and implement process improvement initiatives utilizing quality strategies scaled for efficiency and purpose. Collaborates with key stakeholders to identify data-driven solutions for improvement.

 

Supports a culture of employee engagement to improve patient outcomes and deliver excellent care. Develops customer service training for onboarding and on-going training as well as just-in-time curriculum content for new initiatives and for new staff members related to core quality functions.

 

Works with hospital leadership to establish a robust patient experience program incorporating patient-centric programs founded in �best-practice� models. Listening to the health consumer and creating innovative solutions for the diverse patient population leveraging the services The Miriam Hospital.

 

Assists the Vice President of Quality and Safety in planning activities to ensure dissemination of information for hospital-wide and system-wide improvement efforts. Directs the flow of relevant information to appropriate hospital and Lifespan representatives and committees.

 

Facilitates assessment and resolution of family/visitor issues. Establishes themselves as an expert resource for leaders staff and providers on patient relationship development and general clinical quality outcomes measurement.

 

Serves as a liaison to the Lifespan system quality improvement team and to the Miriam Hospital Medical staff departments for coordination of quality improvement actions involving patient care processes and physician processes. Promotes meaningful communication and performance improvement information among and between Lifespan and the Medical Staff.

Facilitates and coaches staff leading teams working to improve performance. Coordinates and supports the implementation of improvement tactics in alignment with organizational priorities. Identifies and presents best practices and other tactics needed to improve performance. Presents educates frontline staff and other key stake holders on tactics and execution. Monitors and makes suggestions to improve best practices and their integration into existing systems.

Consistently applies and serves as a role model for the Lifespan shared �CARE� values of Compassion Accountability Respect and Excellence. Is responsible for knowing and acting in accordance with the principles of the Lifespan Corporate Compliance Program and Code of Conduct. Provides support and leadership for Lifespan�s Quality Priorities service and treatment settings.

Performs other duties as assigned.

PERFORMANCE STANDARDS:

Effective utilization of resources

Management of continuous quality improvement

High quality high value patient-focused services

Resource productivity

Fiscal responsibility

Development and implementation of effective quality programs

Customer satisfaction

Performance improvements methodologies and approaches

Positive feedback from peers directs reports and staff

Development and implementation of effective quality programs

Performance improvements year-to-year

Positive feedback from peers directs reports and staff

 

Other information:

QUALIFICATIONS-EDUCATION:

A bachelor�s degree in nursing or healthcare related discipline is required. Master�s degree in related healthcare field required. Six Sigma Black Belt certification or equivalent experience leading performance improvement projects preferred. CPHQ CPPS or other quality certifications preferred.

QUALIFICATIONS-EXPERIENCE:

A minimum of seven (7) years of related experience is necessary particularly in quality measurement and reporting systems oversight over physician peer review programs and process evaluation and improvement. Extensive knowledge of performance improvement systems and/or process improvement methods and standards. Effective project management skills are required. Must have experience with electronic health record applications and modules Microsoft Office Suite (e.g. Word Excel Access PowerPoint) other computer applications database development and outcomes management.

Strong group facilitation and project management skills required. Ability to collaborate and lead various project teams. Solid written/verbal presentation critical thinking and analytical skills required.

SUPERVISION:

Supervisory responsibilities for up to twenty professional and support staff. Includes selection direction and evaluation of work.

 

Lifespan is an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race color religion sex national origin age ethnicity sexual orientation ancestry genetics gender identity or expression disability protected veteran or marital status.   Lifespan is a VEVRAA Federal Contractor.

 

Location: Corporate Headquarters USA:RI:Providence

 

Work Type: Full Time

 

Shift: Shift 1

 

Union: Non-Union

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