Vice President of Quality & Safety in Owosso, Michigan at Memorial Healthcare

JOB SUMMARY

The Vice President of Quality & Safety works under the general supervision of the Chief Executive Officer (CEO) and Chief Medical Officer (CMO). Responsible for defining and developing a culture of excellence and high reliability in the organization. Responsible for providing organizational leadership and coordination of activities related to performance improvement, patient safety, risk management, infection control and employee safety. Provides oversite of personnel and activities related to data collection and analysis, performance improvement initiatives, infection prevention and employee health. Provides expertise on compliance with federal, state, and accreditation agencies and regulations and facilitates on-going accreditation readiness for the organization. Strives for superior performance by consistently providing a product or service to; leadership and staff that is recognized as ultimately contributing to the patient and family experience. As a customer-focused team member he/she must be accessible, flexible, knowledgeable and responsive.

JOB RELATIONSHIPS

RESPONSIBLE TO: Chief Executive Officer, Chief Medical Officer

WORKERS SUPERVISED: Quality Improvement, Risk Management, Infection Control, and Employee Health, Long Term Care, The Meadows, Behavioral Health

INTERRELATIONSHIPS: Administration, employees, medical staff, volunteers, community agencies, patients, and families

PRIMARY JOB RESPONSIBILITIES

1. Responsible for providing oversight and strategic direction for The Meadows (assisted living)
2. Responsible for providing oversight and strategic direction for Long Term Care.
3. Responsible for providing oversight and strategic direction for Behavioral Health and Recipient Rights.
4. Collaborates with staff, medical staff and leadership to ensure organizational compliance with quality and value-based purchasing initiatives directed by regulatory/accreditation/payer organizations such as Joint Commission, CMS, and BCBS.
5. Oversee organizational performance and quality improvement activities, risk management, infection control, and employee health, providing direction and support as appropriate. Advise leaders and the medical staff on trending and activities that impact the organization.
6. Assist with development and implementation of the organization’s performance and quality improvement plan in accordance with the mission, vision, values and strategic goals of the organization; federal and state laws, regulations, and accreditation standards.
7. Monitors regulatory bodies (federal and state), professional organizations and accrediting bodies for changes in laws/regulations which have the capacity to impact the organization’s level of compliance. Disseminates information to the appropriate leaders and provides oversight to ensure compliance is achieved.
8. Actively leads and participates in assigned hospital committees such as; Quality and Safety Committee, Board Performance Improvement Committee, Accreditation Readiness.
9. Maintains responsibility for assigned budgets. Participates in the annual planning and development of budgets for responsible departments.
10. Oversees the hospital employee health program related to infection control, including TB testing, pre-employment titers, appropriate vaccinations, flu shots, and follow up on employee exposures to bloodborne pathogens and employee injuries.
11. Oversees worker’s compensation cases and works with physicians and worker’s compensation administrator to return the employee to work with optimal outcomes after an injury.
12. Collects, reviews, analyzes and interprets surveillance data. Identifies opportunities for improvement and recommends appropriate actions to clinicians and administrators targeted to reduce or eliminate harm to patients and staff.
13. Plans, organizes, develops, coordinates and directs a hospital wide plan for the prevention, surveillance, and control of infection.
14. Develops, review, evaluates and implements employee health and infection control policies and procedures to improve quality of care and meet current recommended guidelines.
15. Acts as liaison to the Public Health Department, CDC, and OSHA.
16. Demonstrates knowledge of and supports hospital mission, vision, value statements, standards of care, policies and procedures, operating instructions, confidentiality statements, corporate compliance plan, standards of behavior, and the code of ethical behavior.
17. Must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of patients served on his/her assigned unit. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the unit's and division's policies and procedures. (See attached for specific age ranges of patients served.)
18. Other duties as assigned.

JOB SPECIFICATIONS

EDUCATION

1. Graduate from an accredited school of nursing.
2. BSN required, MSN preferred.
3. Licensed as a Registered Nurse in the State of Michigan.

JOB KNOWLEDGE & EXPERIENCE

1. Minimum of three years’ experience in management and supervision required. Two to three years previous experience in performance and quality improvement, infection control and employee health preferred.
2. Knowledge of the basic principles of management and supervision, including human resources management, performance improvement, information technology, departmental planning, service programming, budget, staffing and other appropriate leadership skills.
3. Knowledge of Joint Commission standards and CMS regulations.

ESSENTIAL PHYSICAL REQUIREMENTS

These physical requirements are not exhaustive and additional job-related physical requirements may be added on an as needed basis. Corrective devices may be used to meet physical requirements.

1. Sedentary Work: Frequently required to stand, kneel and crouch. On a daily basis may be required to move about, sit, climb stairs and bend. Is frequently required to lift and carry up to 20 lbs. May be required to push/pull/carry items between 20-100 lbs.
2. Vision: Requires the ability to perceive the nature of objects by the eye. Near acuity: Clarity of vision at 20 inches or less. Midrange Acuity: Clarity of vision at distances of more than 20 inches and less than 20 feet.
3. Motor Coordination: While performing the duties of the job, it is required to regularly perform functions that include using hand and finger movement, handle or feel objects, be able to use tools or equipment that requires reaching with hands and arms. Must be able to travel independently throughout the hospital; access patients/families including areas confined by space and/or equipment.
4. Speaking/Hearing: Ability to give and receive information through speaking and listening.

ESSENTIAL MENTAL ABILITIES

1. Ability to adapt and maintain focus in fast paced, quickly changing or stressful situations.
2. Ability to read and interpret a variety of documents including, but not limited to policies, operating instructions, white papers, regulations, rules and laws.
3. Ability to perform independently, assess, evaluate and manage complex problems, determine project guidelines and follow through with completion of activities.
4. Ability to delegate, direct, evaluate, and manage staff.
5. Ability to think strategically, lead teams and provide project planning.
6. Ability to comprehend and utilize various computer programs.
7. Organize information and present to a variety of audiences in an understandable manner.

ESSENTIAL TECHNICAL/MOTOR SKILLS

1. Be proficient in the use of appropriate computer applications such as Microsoft Office including Excel spreadsheets for statistical tracking and reporting, and PowerPoint presentations.
2. Be proficient in use of the internet to perform appropriate research.

Hand-eye coordination to operate equipment.

ESSENTIAL SENSORY REQUIREMENTS

1. Able to see for the purpose of reading information received in formats including but not limited to paper, computer, reports, bulletins, updates, manuals.
2. Communicate receptively and expressively in English, both written and spoken, with physicians, patients, families, community agencies, employees and volunteers.
3. Ability to document pertinent data.
4. Receive and interpret data/information.
5. Respond to verbal and written requests.
6. Accurately hear communication by phone or in person.
7. Maintain self-control.

INTERPERSONAL SKILLS

1. Ability to interact with co-workers, hospital staff, administration, patients, physicians, the public and all internal and external customers in a professional and effective, courteous and tactful manner, at all times, physically, verbally and in all written and electronic communications.
2. Remain calm and in control under high stress conditions.
3. Maintain a professional and courteous manner.
4. Maintain confidentiality.