Director - Quality & Safety

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Director - Quality & Safety

Position Objective :

Under the direction of the VP, Quality and Safety, the Director, Quality and Safety identifies, develops, formulates, and implements strategic goals and objectives for Luminis Health’s (LH) Quality and Safety program.

The Director will work with the acute care hospitals, the LH ambulatory practices, clinicians, health system leaders, and interdisciplinary teams to consistently deliver measurable improvements and provide structure to assure the achievement of quality and safety goals and regulatory compliance as a high reliability organization.

Staff the Director will directly supervise and lead are at the two acute care hospitals locations (the Anne Arundel Medical Center is in Annapolis and Doctors Community Medical Center is in Lanham);

the Director is expected to split time on-site at both hospitals.

Essential Job Duties :

Participates, with other senior ambulatory and hospital personnel in the analysis, planning and strategy formulation of ambulatory and hospital entity goals and the implementation of plans and programs;

analyzes operations and clinical outcomes to determine potential enhancements or improvements to processes and activities.

• Key leader in the development, monitoring and ongoing refinement of quality and safety standards across all hospital, ambulatory and medical groups of Luminis Health including office practices and extension with community partners.
• Provides support and leadership in the areas of clinical performance and process improvement, guidance and / or facilitation in response to risk, safety, and licensing requirements for the organization to create a high reliability organization as outlined in LH Quality and Safety Plan.
• Leads, monitors and trends root cause analysis (RCA) and any actions resulting from root cause analysis and case reviews and reports back findings and updates.
• Manages projects to ensure timely completion of reports by identifying data sources, collects data to establish quality and patient safety measures, coordinates with data analysts and tracks data specifications and facilitates meetings, bridging the analytics to clinical and operational requirements.
• Triages the urgency of safety events alerting the Vice President of Quality and Safety and operational leaders to activate resources if needed.
• Provides general education about quality and process improvement tools, patient safety and processes involved with event reviews to clinical staff and graduate medical education trainees.
• Provides leadership / administrative coordination for and participates in the LH System Quality Council and LH Patient Safety Committees.
• Gathers data from internal and external (local, state and national) data sources to establish benchmarks / goals for Quality and Safety indicators and works with LH Data Specialists to provide data reports for enterprise executives and Service Line Quality Councils.
• Develops and implements methods of systemic performance improvement as Supervises all staff within the LH Quality / Safety Department and manages the department budget.

Educational / Experience Requirements :

The minimum level of education and experience for this position includes :

• Completion of formal M.S. degree in healthcare related field from an approved educational institution.
• Five to eight years in health care with increasingly complex management experience demonstrated. With at least 5 years’ experience in the provision of Quality and Safety Management.
• Experience with word processing and spreadsheet applications, Microsoft Teams and Microsoft Outlook.
• Demonstrated understanding and implementation of continuous quality improvement methodologies in a health care setting.

TeamSTEPPS, and Lean SixSigma proficiency experience preferred.

• Demonstrated knowledge of federal and state regulations related to health care as well as knowledge of Joint Commission healthcare standards, CMS, NCQA, State of Maryland, and other legislative and regulatory initiatives.
• Experienced with High Reliability and Safety initiatives, Just Culture and with electronic quality data tools / systems.
• Demonstrates strong interpersonal skills and relationships with all levels of hospital and medical staff and Board of Directors.

Required License / Certifications :

• CPHQ or CPPS certification preferred.
• Current licensure as a registered nurse by the Board of Nursing or equivalent clinical certification preferred.

Working Conditions, Equipment, Physical Demands :

There is a reasonable expectation that employees in this position will be exposed to blood-borne pathogens.

Physical Demands Light Duty

The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.

The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position;

your supervisor may assign other duties as deemed necessary.

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