Director Clinical Quality & Patient Safety

POSITION SUMMARY

The Senior Clinical, Quality and Patient Safety Director (Executive Director), Department of Surgery has direct responsibility for overseeing, creating, implementing and evaluating all quality and patient safety programs for all specialties in the Department of Surgery. The director independently leads a team to provide comprehensive direction, oversight and leadership to improve outcomes, diminish cost and provide value through standardization of best practices in patient centered care across all service lines and hospital wide based on BMC strategic plans.

This position requires extensive cross-functional and system wide relationships beyond the Department of Quality and Patient Safety to be successful in a highly multidisciplinary and complex role. Oversees all aspects of quality program including quality measurement, external reporting, root cause analysis, failure mode analysis and system design. Drives the organization to improve value has extensive knowledge of all aspects of hospital clinical operations as it relates to patient safety, quality, and regulatory accreditation.

The Director coaches, mentors and provides research opportunities to improve patient outcomes, clinical efficiency, value and patient satisfaction. Highly involved in using innovation to continuously move the Department of Surgery forward in an academic setting.

• Works independently to establish and provide comprehensive direction and oversight by leading a team to provide sophisticated analysis, advice and consultation to surgical divisions as well as hospital wide based on BMC and surgery strategic plan.
• Accountable for ensuring issues of highest criticality and complexity are solved in support of clinical organizational goals
• Responsible to identify, design and lead change initiatives that compel higher performance safer systems and clinical excellence.
• Well versed in regulatory standards, requirements, guidelines for Joint Commission, CMS and DPH.
• Establishes oversight and monitoring to maintain compliance with regulatory accreditation in Kidney Transplant, TACS and other surgical divisions
• Fosters professionalism, actively engages department leaders and team members to create a positive supportive culture for staff, patient and families creating a culture of safety
• Provides visionary leadership to ensure BMC is striving for performance excellence that is important in the future of innovative healthcare
• Ensures patient safety events are tracked, categorized and analyzed for improvement opportunities and oversees investigative process for evaluating adverse events and near misses
• Responsible for management of high risk, problem prone areas of opportunity for improvement and ensures problems are prioritized and leading teams working to resolve them
• Ability to demonstrate sound critical thinking and decision making demonstrating cooperative communication working with others to problem solve challenging issues
• Collaboration and partnership with Department Chairs/Chiefs, Nursing Leadership and Administration to plan, develop, and enact interdisciplinary efforts regarding current and future surgical/hospital wide improvement projects
• Thoroughly analyze trends and areas of opportunity based on surgery databases, Vizient, ARHQ,CMS and other emerging quality measurements, directing the development and implementation of new clinical programs improving outcomes with increased efficiency and value
• Involvement in high-priority projects as they occur
• Identification of clinical problems leading teams to monitor and improve clinical effectiveness utilizing rapid cycle approach and systems-based strategies and interventions, coordinating efforts with leaders/staff throughout the organization
• Build strong collaborative relationships at all levels with multidisciplinary/interdepartmental teams to accomplish goals and promote favorable change
• Demonstrate excellent leadership, communication skills, creativity and enthusiasm for developing innovative quality improvement programs
• Oversee standardized practices and systems (e.g. ICOUGH, Caprini VTE etc.) including support and collaboration with other departments
• Oversee teams that coordinate and standardize multidisciplinary care including Surgery, QI, Anesthesia, ED, Nursing and Medicine
• Restructure the Pre Procedure Clinic to a model of risk assessment, risk stratification and patient education looking at improving the model and fast-tracking patients to increase the overall volume and enhance patient safety
• Enhance perioperative communication among surgeons and their teams improving outcomes by focusing on patient –centered care with standardization of pre-op and post-operative discharge instructions
• Oversee the development of a multidisciplinary team to focus on standardization of discharge instructions throughout the Division of surgery, with online and…