Mkt Director Quality Patient Safety - Brazos Valley

Within the role of Market Director, the incumbent provides leadership in defining, implementing and integrating quality, safety, service and efficiency strategies into the plans, policies, and organizational processes that affect the organization’s operations and strategic direction in the overall management of the Market. Collaborates with other leadership team members in the common goal of standardization, integration and enhancement of the continuum of services available within the market’s designated clinical area(s). Supports the individual care sites within the Markets’ Performance Improvement Plans, which identify opportunities for improved patient care and outcomes and reductions in harm, with the implementation of evidence-based practices. Supports the regional Director of Patient Safety with the implementation of high reliability organizational processes within the Market. Oversees implementation and maintenance of system, regional and market standards for quality, performance improvement, peer review, and regulatory compliance across the continuum. Provides reporting as directed within the Market to the Community, Fiduciary, Hospital, JOA and other relevant governance Boards with delegated authority over patient care, quality and patient safety.

* Masters degree Preferred

* Experience in a matrix management environment involving integration of multiple entities is strongly desired.

• Provides leadership oversight and direction to the Market’s quality hospital leaders.
• Collaborates with leaders responsible for centralized services (e.g. Home Health, Living Communities, Physician Enterprise) to develop and implement an integrated, standard approach to quality across the Market’s care continuum.
• Supports the quality and patient safety committee(s) and improvement structure in the market and care sites.
• Serves as a member or quality liaison to community partners and / or Joint Venture partners within the market service area.
• Collaborates in the establishment of performance improvement goals annually with relevant stakeholders. Develops and implements processes and formats which support data collection, aggregation, analysis, and action planning. Assures clinical data is managed appropriately and disseminated to appropriate leadership staff.
• Provides leadership, direction and support in conjunction with the Regional Vice President of Quality and Patient Safety and the Director of Patient Safety of the development, implementation, oversight and maintenance of quality outcomes and goals across the continuum.
• Collaborates with Managed Care leaders for pay for performance measures specific to the Market.
• Participates in national office and the regional initiatives and programs to mitigate risks in the market which have been identified at other healthcare facilities, resulting in reduced costs, a decrease in adverse patient events/outcomes and ultimately safer patient practices and care.
• Facilitates the advancement of High Reliability Organizational work and patient safety efforts.
• Collaborates with the Medical Staff and Regional/Organizational Leadership to develop and enhance safe patient care while achieving optimal outcomes, including the Market’s peer review program and ongoing and focused practitioner evaluation.
• Has a matrix accountability relationship with the Market Chief Medical Officer.

Required Education and Experience:

Bachelors of Science Degree or Equivalent in a related clinical discipline.

Minimum of 5 of healthcare experience with progressive management responsibility in an acute care setting including leading quality.

Experience leading quality, safety and performance improvement initiatives across the care continuum and an integrated delivery network.

Experience developing and implementing clinical, service and operational process improvement initiatives, both small and large scale.

Required Licensure and Certifications:

CPHQ or HCQM or CPQPS within 24 months

Required Minimum Knowledge, Skills, Training and Abilities:

• Knowledge of quality management methods, tools, and techniques and ability to create and support an environment that meets the quality goals of the organization.
• Knowledge and expertise in specific performance improvement/CQI methodologies (e.g., Six Sigma, LEAN).
• Current knowledge of accreditation and regulatory requirements for acute and ambulatory care services (e.g. state, federal, local regulations, The Joint Commission).
• Knowledge of federal, state and local healthcare related laws and regulations; ability to comply with these in healthcare practices and activities.
• Knowledge of the risks faced by patients in a healthcare environment, and the ability to take steps to reduce these risks.
• Knowledge of the critical interdependencies among system elements that help and hinder performance and ability to plan and design solutions that synchronize resources to achieve business results.
• Ability to oversee and positively impact clinical operations in a healthcare organization.
• Understands the importance of striving toward a zero defect production goal and ability to establish methods and metrics that deliver targeted standards for products and services.
• Solid understanding of the business and financial considerations of a healthcare organization.
• Ability to manage collaboratively and coaches others to achieve optimal performance; delegate effectively; praise/reward contributions; define clear roles and responsibilities; set goals and lead initiatives; adjust plans as necessary.
• Ability to anticipate, recognize, and deal effectively with existing or potential conflicts at the individual, group, or situation level; ability to apply this understanding appropriately to diverse situations.
• Ability to identify opportunities and take action to build strategic relationships between one’s area and other areas, teams, department, units or organizations to help achieve business goals.
• Excellent communication skills (oral and written), presentation style, including the ability to concisely present data to leaders, clinicians and staff at all levels of the organization

St. Joseph Health – Bryan/College Station, Navasota, Caldwell, Madisonville, TX. Since 1936, St. Joseph Health has been caring for the communities in and surrounding the Brazos Valley. We have a Level III Trauma Center, the first Joint Commission certified Primary Stroke Center, and the first accredited Chest Pain Center in the Brazos Valley. St. Joseph Health is a leader in critical care and the largest provider of cardiovascular care in the region. As an integrated healthcare system St. Joseph Health includes a comprehensive network of over 100 employed providers including primary care physicians specialists and advanced practice clinicians. The network includes more than 30 ambulatory clinics featuring primary care, Express Clinics, and imaging and diagnostic services.

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