Overview

Responsible for developing a vision and executable plan to attain world class quality and safety processes and procedures across the hospital and all hospital outpatient departments (HOD) and including any associated Health Parks. Accountable to ensure successful development and deployment of the WellStar Quality and Safety strategy in a manner that supports achievement of WellStar Quality goals. Bringing patient safety and clinical quality expertise, he/she will partner with leadership, staff and system partners to identify opportunities for short and long-term impact on quality and safety outcomes in alignment with WellStar's strategic plan.

Plans, organizes and directs all services and operations of the department which includes quality performance improvement, continuous survey readiness, and infection prevention programs for the hospital. Works collaboratively with hospital Vice Presidents, Directors and Managers, as well as system leadership and peers to align department goals with Hospital and System strategic goals. Oversees daily operations to ensure delivery of high quality services and support and execution of tactics designed to meet the goals. Is responsible for coordinating activities of Quality Committees with appropriate personnel, including medical staff Quality, PI and peer review committees. Ensures processes in support of accurate and high performing publicly reported quality data, WellStar quality goals and applicable data registries. Leads hospital implementation and ongoing support of Lean PI methodology.

Serves as an influential champion for the WellStar Safety First program, supporting a fair and just culture of safety, accountability and organizational learning. Works to effectively integrate functions and coordinate collaboration across the care continuum. Partners with external organizations to ensure regulatory and accreditation standards compliance and to infuse best practices into improvement efforts.

The individual in this role will proactively identify opportunities to optimize performance, build internal competencies, foster a strong and empowered team, and create a rigorous approach to quality and safety throughout the organization, with a strong focus on the patient, accountability and appropriate use of resources.

Responsibilities

Qualifications

Required Minimum Education

• Bachelor's Degree in Nursing, Healthcare Quality, Business, Public Health or a related field is required.
• Master's Degree in Nursing, Healthcare Quality, Business, Public Health, or a related field or completion within two years of start date in role is required.

Required Minimum Experience

• Minimum 5 years of progressive experience in healthcare quality services or support is reequired. 
• Minimum 2 years experience in managing a team directly is required.
• Minimum 5 years of experience with significant project or functional leadership within quality services.
• Previous experience with proven leadership in regulatory and accreditation survey readiness, quality improvement and patient safety in a large acute care system or facility required, including demonstrated ability in interpreting quality metrics to lead actionable change is required. 
• Strong experience with patient safety event management, including conducting root cause analysis and facilitating creation of effective, timely action plans is requred. 
• Experience leading improvement work using a scientific methodology is required. 
• Lean management system and Lean Production System methodology is preferred. 
• Experience coordinating with and reporting data to a Patient Safety Organization (PSO) is preferred. 
• Experience managing and/or monitoring infection prevention functions is preferred. 

Required Minimum Skills

• Strong interpersonal skills with the ability to communicate and work with all levels of healthcare providers including physicians.
• Ability to perform duties and responsibilities promptly and consistently with little direct supervision.
• Ability to execute a plan and use project management methodology.
• Ability to plan and direct activities of others and provide feedback regarding outcomes or performance.
• Ability to work collaboratively with other departments within and outside the Hospital.
• Ability to judge the appropriate action in response to changes, circumstances, or problems.
• Experience in data collection, analysis and project management required.
• Strong computer skills required.
• Excellent communication, presentation and organization skills required.
• Working knowledge of data collection methodologies, interpretation/analysis and decision support databases.
• Exposure to workflow in event management systems with the ability to interpret and utilize trended event data to improve safety.

Required Minimum License(s) and Certification(s)

• Cert Prof Healthcare Quality is required