Director of Quality & Patient Safety Officer

---

Job description

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 Education Bachelor's degree required
Required Skills Certifications: 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 Experience Three (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 ( Infant ( Early Childhood (1 year and Late Childhood (5 years and Adolescent (13 and Young Adult (17 to Middle Adult (30 years to Older Adult (>60 years)
Protected Health Information Type of Protected Information Accessed: Demographic Clinical Insurance Financial Complete Medical Record
Bloodborne Pathogens Exposure While performing this job, occupational exposure is present for all employees
Physical Requirements - Physical Dexterity and Effort: Rarely Bending/Stooping rarely, X occasionally, frequently, constantly Climbing X rarely, occasionally, frequently, constantly Keyboard Data Entry rarely, occasionally, X frequently, constantly Kneeling X rarely, occasionally, frequently, constantly Lifting/Moving Patients rarely, X occasionally, frequently, constantly Reaching X rarely, occasionally, frequently, constantly Repetitive Foot/Leg Movements X rarely, occasionally, frequently, constantly Repetitive Hand/Arm Movements rarely, occasionally, X frequently, constantly Running X rarely, occasionally, frequently, constantly Sitting rarely, occasionally, X frequently, constantly Squatting X rarely, occasionally, frequently, constantly Standing rarely, X occasionally, frequently, constantly Walking rarely, X occasionally, frequently, constantly Pushing / Pulling: 0-25 lbs. rarely, X occasionally, frequently, constantly Pushing / Pulling: 26-75 lbs. X rarely, occasionally, frequently, constantly Pushing/Pulling: over 75 lbs. X rarely, occasionally, frequently, constantly Lifting/Carrying (non-patient) : 0-25 lbs. rarely, X occasionally, frequently, constantly Lifting/Carrying (non-patient) : 26-75 lbs. X rarely, occasionally, frequently, constantly Lifting/Carrying (non-patient) : over 75 lbs. X rarely, occasionally, frequently, constantly
Visual Acuity, Hearing and Speaking: Rarely Audible Speech rarely, occasionally, X frequently, constantly Hearing Acuity rarely, occasionally, X frequently, constantly Smelling Acuity X rarely, occasionally, frequently, constantly Taste Discrimination X rarely, occasionally, frequently, constantly Vision: Depth Perception rarely, occasionally, X frequently, constantly Vision: Distinguish Color rarely, occasionally, X frequently, constantly Vision: Seeing Far rarely, occasionally, X frequently, constantly Vision: Seeing Near rarely, occasionally, X frequently, constantly
Biological: Rarely Biohazardous waste/ hazards rarely, X occasionally, frequently, constantly Blood and/or bodily fluids rarely, X occasionally, frequently, constantly Communicable diseases/pathogens rarely, X occasionally, frequently, constantly
Chemical: Rarely Asbestos or lead X rarely, occasionally, frequently, constantly Cytotoxic Chemicals X rarely, occasionally, frequently, constantly Dust X rarely, occasionally, frequently, constantly Hazardous Chemicals X rarely, occasionally, frequently, constantly Gases/Vapors/Fumes X rarely, occasionally, frequently, constantly Hazardous Medication X rarely, occasionally, frequently, constantly Latex 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.

Equal opportunity and affirmative action employers and are looking for diversity in candidates for employment: Minority/Female/Disabled/Protected Veteran

<!– job description page –>