Senior Director Quality Safety & HIM

Director of Quality, Safety, Accreditation, Risk and HIM

The Director of Quality, Safety, Accreditation, Risk and HIM is responsible for planning, organizing and managing the coordination of the organization's performance improvement activities, required measurement and monitoring. The Director is responsible for the planning and coordination of the tri-annual Joint Commission and all other regulatory body surveys. The Director's responsibilities also include facilitating cross functional teams and the development and maintenance of a project management infrastructure to support business development. The Director will plan, organize, analyze and manage the reporting of outcomes for MedStar Southern Maryland Hospital Center and MedStar Health. This position functions as the hospital risk manager, providing risk identification and control through analysis of incident patterns and cases involved in litigation. This position oversees the function and impact of the HIM department and effectively plans and coordinates the activities of HIM, Joint Commission and other regulatory agencies. Communicates needs and revised program objectives to hospital management to maintain the Risk Management Program.

Primary Duties and Responsibilities

• Quality & Accreditation - Develops and contributes to the achievement of established department goals and objectives and adheres to system, hospital and department policies, procedures, quality standards and safety standards.
• Ensures compliance with hospital / facility policies and procedures and governmental / accreditation regulations. Works with the Hospital Leadership to achieve the objectives of the programs via reviews, relevant training, and systematic implementation of policies. Assists with policy and procedure development. Implements the Improving Organizational Performance Program and maintain policies and procedures to ensure optimum hospital quality, safety, and efficiency.
• Provides education and orients hospital / medical staff with regard to Performance Measurement. Implements and monitors the Performance measurement and Performance Improvement Programs. Directs and coordinates the assessment, planning, implementation and evaluation of the Performance Measurement System - Outcome Measurement Program.
• Assures data integrity and reporting for the MHA, State of Maryland, Core Measurement, publicly reported data sources, and other external databases. Adapts continuous process improvement tools for decision support, such as data mining, statistical process controls, cueing theory, quality function deployment, failure modes and effects analysis, modeling, simulation and human factors engineering to health care delivery to be used by clinicians, care teams and administrators to improve the performance of discrete care processes.
• Mentors and evaluates staff; provides direction for departmental operations. Provides the oversight and maintenance of a comprehensive, user friendly outcome management database, examining the data for accuracy, and updating the program to meet changing database needs. Keeps abreast of new methodologies, processes, management and organization trends, best practices and emerging philosophies in the fields of performance measurement and organizational development.
• Develops goals and an annual plan for the Performance Measurement System / Outcomes Measurement Program that is consistent with the goals and philosophy of the Hospital and MedStar. Independently oversees the daily operations with consistent focus on quality, safety, and accreditation.
• Analyzes reports results of the hospital's performance efforts and matters relating to quality, safety and business development to the Vice President, Medical Affairs and other administrators as requested.
• Safety & Risk Management - Functions as the hospital risk manager, providing risk identification and control through analysis of incident patterns and cases involved in litigation. Communicates needs and revised program objectives to hospital management to maintain the Risk Management Program. Refers findings to oversee the creation, review, and refinement of the scope of the Patient Safety Program within the facility on an annual basis. Barriers to the implementation of safety programs should be addressed. Performs other duties as assigned.
• Acts as the designated hospital liaison to the MedStar Risk Management program and other liability carriers for preparation of cases undergoing litigation and when legal or liability consultative information is required. Provides in-service education and orients hospital / medical staff with regard to Risk Management. In accordance with the Risk Management Plan, administers the variance reporting system, conducts investigations, compiles and analyzes data to identify trends.
• Oversee the management and use of medical error information. Review internal error reports and utilize information from external reporting programs. Investigate patient safety issues within the facility. Participate and may facilitate in Root Cause Analysis of internal error report. Recommend and facilitate change within the organization to improve patient safety, based on identified risks. Collaborate in the development of policy and procedures effecting organizational safety. Develop a mechanism for internal communication of patient safety related information.
• Design and implement educational presentations that facilitate the understanding and implementation of patient safety standards within the organizations. Serve as a resource for clinical departments on issues of patient safety. Support and encourage error reporting throughout the organization through a non-punitive error reporting system.
• Manages the compliant and grievance process within the organization in accordance with policy and state regulations. Report written information to the governing body and MEC on the occurrence of known medical and health care errors and identified near misses and dangerous conditions within the facility as well as actions taken, either proactively, or based on occurrences.
• Health Information Management - Effectively assists in the planning, development, and revision of policies and / or programs related to HIM and other departments. Responsible for coordinating all activities related to Meaningful Use, Facility Privacy, Recovery Audit Contract (RAC) and Facility Records Management.
• Establishes and submits an annual HIM plan with associated objectives based on the overall goal of the institution. Participates in meetings and special task force as needed.
• Manage and direct the operation and activities of the entire HIM function, including medical records, coding, and transcription at multiple facilities.
• Responsible for management of the Department's daily operations to maintain quality, fiscal productivity and patient satisfaction goals, including additional objectives established by upper management.
• Responsible for staff performance and meeting all departmental responsibilities. Responsible for providing high-quality service to and acting as a liaison to patients and their representatives, physicians, and employees. Responsible for optimum use of Department resources to maximize productivity and minimize costs.

Minimum Qualifications

Education : Master's degree in administration or healthcare related field required and Knowledge of continuous quality improvement, processes and methodologies, Joint Commission Standards and CMS Conditions of Participation required.

Experience : 3-4 years in accreditation / regulatory affairs / performance improvement / patient safety in health care required and 5-7 years managerial experience required and Knowledge of risk / safety event reporting software preferred.

Licenses and Certifications : Certification in Quality preferred and Patient Safety Officer Certification preferred.

Knowledge, Skills, and Abilities : Ability to comprehend and follow the policies and procedures for MedStar Southern Maryland Hospital Center. Ability to read, write and speak or communicate in English to successfully accomplish the essential duties of the position. Ability to demonstrate ethical behavior that supports the hospital's mission, values and commitment to compliance with all federal, state and regulatory laws. Inspires trust and exhibits honesty and integrity within the scope of daily activities. Exhibits professionalism, courtesy and excellent customer service, while interacting with patients, guests and co-workers. Ability to work effectively with people from a variety of culturally diverse backgrounds. Ability to maintain patient confidentiality, knowledge of risk management principles and issues regarding patient safety. Knowledge and skill to demonstrate strong leadership and management qualities (task completion, delegation, motivation, supervision). Knowledge of accreditation standards, health care regulations, performance improvement and methods, patient safety and policy formulation. Ability to work with a variety of disciplines and levels of staff across department and the health system is required. Effective organizational, oral and written communication skills, problem solving, program development, computer skills, strong leadership, and team building skills.

This position has a hiring range of $131,497 - $256,630