What is the role of a Director, Quality & Patient Safety at Alice Peck Day Health System?

The Director, Quality & Patient Safety position at Alice Peck Day Health System is a Full-time or part-time position opportunity in the relevant field.

Where is this Director, Quality & Patient Safety job located?

Lebanon, New Hampshire, 03766, United States

What type of employment is offered for this Director, Quality & Patient Safety role?

Full-time or part-time position

What industry does this Director, Quality & Patient Safety position belong to?

This role spans multiple industries.

What is the expected salary for this Director, Quality & Patient Safety job?

Compensation will be discussed during the hiring process.

How can I apply for the Director, Quality & Patient Safety position at Alice Peck Day Health System?

You can apply directly through the application link provided.

Director, Quality & Patient Safety at Alice Peck Day Health System

*Greenbelt in process improvement methods or equivalent with 5 years of experience leading improvement or system design projects required

Reports to:
- Chief Medical Officer within a highly matrixed relationship with the Chief Nursing Officer and Chief Executive Officer
Position Standards:
- Master's in Business or Health Care Administration desirable
- Clinical Profession licensure in NH required ; Licensed Registered Nurse in New Hampshire preferred; will consider other clinical areas of licensure. Certification in modern improvement methodology (Lean, Six Sigma, etc.) and/or Professional Project Management and/or Healthcare Quality preferred.
- Master's degree and 5 years of related clinical supervisory/management experience required. Candidates matriculated into a Master's program will be considered
- Greenbelt in process improvement methods or equivalent with 5 years of experience leading improvement or system design projects
- Excellent organizational, interpersonal, oral and writing skills required
- Exemplary leadership qualities
- Prior experience with budgetary preparation and systems development required
- The ability to relate and deal effectively with physicians, administrators, support staff, board members and the general public with a high degree of tact and discretion required
- Ability to develop and present effective presentations to varying audiences across multiple disciplines at all levels of the organization and system
- Working knowledge of statistics and Statistical Process Control
- Expertise in POWERPOINT, WORD and EXCEL
- Expertise in ACCESS or other database programs desired
- Ability to make independent decisions in judgment using general guidelines provided by leadership
Position Physical Requirements:
- Anything listed here requires a pre-employment physical by Employee Health to determine if the employee is capable of meeting the requirements.
  - Physical Activity:
  - Upper Extremity:
  - Push/Pull/Lift/Carry:
Part Two: Performance Expectations - Director
- Patient Focus: Places, first and foremost, the quality of the care and safety of the patient/resident first. Does the right thing for the patient and resident. Maintains disciplined attention to quality, cost and access.
- Knowledge of Profession: Demonstrates comprehensive, current skills and knowledge within area of expertise.
- Respects Rules/Recognizes Boundaries: When going outside own realm of expertise and responsibility, in the service of improving current rules and processes, seeks other's knowledge and ensures the regulatory well being of APD. Respects established organizations rules and accreditation regulations.
- Human Resource Management: Maintains responsibility for the hiring, orienting, development, and recognition of departmental staff. Manages the performance of staff in accordance with Human Resource Policies.
  - Define and document expectations for all direct reports.
  - Grow and develop employees
  - Maintain positive and collaborative relationships with members of the medical staff
  - If challenges arise, partner with VP and HR to initiate, implement, and document improvement plan.
- Financial Stewardship: Plans and adheres to departmental budget. Identifies and takes action on opportunities for cost savings and revenue growth.
  - On a monthly basis, review organization's volumes and department expense budget.
  - Adjust departmental expenses in proportion to volume variances.
  - If leading a clinical department, ensure accurate and complete charge capture and coding.
- Policy Management: Maintains, communicates updates, and enforces departmental policies. Keeping at the forefront, regulatory compliance, quality of patient/resident care and evidence based best practice.
- Confidentiality/Privacy: Follows and ensures staff compliance with APD policies regarding privacy and confidentiality. Remains informed and knowledgeable of HIPAA. Attends all required training.
- Quality/Performance Improvement: Ensures departmental team participation in quality assurance and performance improvement processes. Responsible for ensuring compliance with CMS conditions of participation and other governing bodies for standards of care, where applicable.
Part Three: Performance Expectations - Functional
- Coordinates all quality improvement, quality assurance and performance Improvement activities throughout the hospital and hospital-owned clinics using evidence based proven methodologies such as lean/six-sigma.
- In conjunction with the senior administrative leadership, develops actionable quality metrics and design data collection methodologies.
- Designs and leads the implementation of improvement projects at all levels of the organization.
- Works with the APDMH senior leadership and DH system members when required to achieve strategic goals utilizing continuous quality improvement approaches when appropriate.
- Ensures hospital compliance with Critical Access Hospital (CAH) required appendices and Centers for Medicare & Medicaid Services (CMS) standards related to clinical quality assurance/performance improvement activities. Coordinates efforts to comply with all other regulatory agencies related to quality practices.
- Serves as an expert resource, mentor and coach to all departments regarding improvement activities and supports the training and education of staff in using a standardized approach to process improvement across the organization.
- Uses Statistical Process Control and other appropriate statistical analytic techniques, analyzes data for trends to identify improvement opportunities and assess the organization for system vulnerabilities, to facilitate appropriate improvement activities.
- In collaboration with Risk Management, coordinates the management of clinical adverse event investigations (to include RCA/ACA), risk assessments and follow up on corrective actions as required by regulators, hospital policy or at the request of senior management using best practice, industry standard methodologies.
- Applies nursing knowledge in formal and informal consultation with individual staff and clinicians, managers, committees/teams and Risk Management to identify and address clinical quality and safety concerns. Chairs the APDMH Quality Committee meeting including the coordination of agendas and minutes
- Assembles and disseminates identified quality reports to all levels of the organization. Presents data in a clinically relevant manner to all stakeholders.
- Responsible for the annual review of the Quality Assurance and Process Improvement (QAPI) program to include the development, review and annual update. This includes the development and dissemination of the QAPI Annual Report
- Applies advanced skills in change management to maintain and promote a harmonious work environment across departments to assure alignment on clinical quality and safety projects.
- Attends the New Hampshire Quality Commission (NHQC) and New Hampshire Hospital Association meetings and ensures that APDMH fully participates in all required activities.
- Attends and participates in the DH Enterprise System Quality meetings and associated activities. Serves as a liaison to APDMH to communicate and facilitate implementation of DH Quality system level priorities
- Performs other duties as assigned

Director, Quality & Patient Safety at Alice Peck Day Health System – Lebanon, New Hampshire

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