JOB SUMMARY: The Senior Director Clinical Quality, Safety and Risk directs the clinical risk management, patient safety/experience and quality improvement functions. Works with the team to improve the quality and safety of healthcare delivery including ensuring regulatory compliance and proactive risk assessment and actions to prevent or control risks. Fosters cross-functional and system-wide relationships beyond the departments of quality, infection control, employee health and patient safety to be successful in a highly multidisciplinary and complex role. Develops and implements strategies to improve the experience of patients and their families.
EDUCATION, CERTIFICATION, LICENSURE and REGISTRATION:
1. Bachelor's Degree required, Master's Degree preferred.
2. RN license required.
EXPERIENCE, KNOWLEDGE, SKILLS and ABILITIES:
1. Minimum 7 years of progressive management in a healthcare environment, including an extensive background in healthcare operations with specific involvement in quality and patient safety activities.
2. Extensive knowledge of all aspects of clinical operations, as relate to patient safety and quality, as well as infection control, risk management, employee health, and regulatory affairs.
JOB SPECIFIC DUTIES AND RESPONSIBILITIES:
1. Oversees all aspects of the quality program, including quality measurement, improvement and reporting to improve clinical outcomes, enhance value and minimize patient harm.
2. Develops and implements risk mitigation strategies, quality improvement programs, and reviews/establishes internal quality standards.
3. Develops and maintains policies that improve patient care, quality, and safety reducing patient occurrences and other risks. Recommends ways to eliminate or reduce risk through improved processes, equipment or other changes.
4. Collaborates with General Counsel and leadership team to ensure resolution of identified risks.
5. Initiates and oversees the development of a Patient Safety Program including incident reporting, root cause analyses, sentinel event reporting, systems design, failure modes and effects analysis, and proactive staff training and education.
6. Coordinates and oversees data collection, event analysis and classification and follow up to patient safety events to facilitate change and improve patient safety outcomes.
7. Collaboratively ensures that organizational patient safety initiatives are implemented effectively and risk reduction strategies are in place.
8. Oversees the infection control program and collaborates with others to improve infection control measures across the organization.
9. Develops and oversees infection control policies and procedures across the organization consistent with best practice standards and regulatory compliance.
10. Leads a multi-disciplinary Infection Control Committee
11. Coordinates and oversees data collection as it relates to infectious disease processes.
12. Educates team members regarding infection control and their role in protecting themselves and patients from harm during care delivery.
13. Educates patients on patient satisfaction survey process and timing.
14. Responds to and investigates patient complaints and concerns and communicates identified issues to appropriate team members.
15. Uses findings from analysis of trends in complaints and survey results to mentor team members and departments to develop appropriate service action plans.
16. Identifies national best practices around patient experience and supports a culture and standard of care that improves the patient experience.
17. Oversees continual compliance readiness in providing accrediting or licensing body reviews and education