Director of Quality & Patient Safety Job Cambridge area,Massachusetts USA,Healthcare

Position: Director of Quality & Patient Safety, Mount Auburn Hospital
Job Description

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives. Reporting to the Chief Medical Officer, responsible for the oversight, leadership and direction of the healthcare quality and patient safety programs for Mount Auburn Hospital and Mount Auburn Professional Services’ (MAPS) ambulatory practices. Serves as an organizational leader in design, development, implementation and monitoring of quality and safety initiatives, plans, metrics and goals.

Leads change by using continuous performance improvement methods to support ongoing regulatory readiness, improved quality outcomes, reducing preventable harm and improving patient and caregiver experience. The Director of Quality & Patient Safety acts as an expert resource across the organization overseeing complex projects to completion through team facilitation and team building. This role collaborates with leaders and staff, and is a role model and in high reliability, just culture, change management theory, and regulatory standards.

Interacts with the Board of Trustees to support committee meetings. The Director actively leads interventions that reinforce and support a culture of safety and high reliability. This role collaborates with leaders across the organization Root Cause Analysis (RCA), Failure Mode Effects Analysis (FMEA) and other quality and safety tools that support a journey to achieving zero patient harm. Responsible for data submission to clinical indicator and quality measurement systems and internal and external benchmark databases.

Manages direct reports (quality data analysts, Quality and Safety Nurse Specialists and patient relations specialists)

Essential Duties & Responsibilities

Initiates, oversees, and integrates a comprehensive clinical patient safety program as a component of the hospitals' quality services to improve safety of patients, visitors and employees

Collaborates with senior leadership, management and physician colleagues to achieve quality outcomes and programmatic goals
Collaborating closely with the Director of Regulatory Affairs and Performance Improvement, develops the annual PI Plan, Work Plan and goals.

Acts as key resource in Quality and Safety leadership, and works closely with clinical, medical and administrative leadership to promote system wide applications of patient safety, and quality improvement strategies

Identifies root causes of adverse occurrences, reports activities to leadership, and facilitates action plan development to resolve and learnings from occurrences

Coordinates the organization’s safety event reporting program.

Educates staff about reporting responsibilities.
Manage online reporting system, and provides for communication and education for managers and senior leaders.
Oversees the investigation of all sentinel events with the appropriate groups.
Maintains a leadership role in development an institutional culture of patient safety and non-punitive reporting of adverse events.
Coordinates learning and data analysis identified through the incident reporting system.
Oversees the Peer Review process including preparation of case summaries/questions, and supports communication of findings to the Medical Staff Office

Provides leadership to individuals and interdisciplinary teams assure oversight of process and outcome measures, and collaborates with the Director of Regulatory Affairs and Performance Improvement on the reporting of clinical quality measures to Joint Commission, CMS and Mass Health to meet regulatory requirements.

Manages internal Analysts and/or Quality data abstractors to meet all required data reporting, audit and validation requirements.
Deliver presentations on Quality reporting requirements and…