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Director of Quality/Patient Safety/Risk

Qualifications/Duties:
Minimum Education Required: Bachelor's Degree, Master's Preferred.
Minimum Experience Required: 5 years experience in quality management in healthcare field (hospital setting preferred). Demonstrated experience and accomplishments with continuous improvement, quality and patient safety. Experience managing quality, case management, social work, and infection control.
Minimum Licensure/Certifications Required: Licensed as a RN in the State of Texas. Certification in either quality (CPHQ) and/or CPHRM or equivalents required within one year from date of hire.
Minimum Skills Required: Knowledge of industry standards related to Joint Commission, CMS, OSHA, regulatory standards for areas of responsibility. Knowledge of continuous improvement tools and techniques. Must be able to analyze and manage information. Excellent presentation and written skills with the ability to communicate effectively with a wide variety of professional and non-professional stakeholders. Able to supervise a diverse and independent staff. Individual must be self-directed and goal/outcomes/measurement driven. Must be adept at Microsoft Office suite, statistical analyses and displays of information.
Work Hours/Schedule: M-F, 40 hours per week.
Duties/Responsibilities:
Clinical/Business Operations:
Staffing department based on volume making adjustments as necessary.
Managing payroll ensuring that time is being recorded and paid appropriately. Minimize manual payroll corrections through weekly review of payroll data.
Ensuring employee attendance at town halls, brown bags, and employee forums.
Ensures the department complies with regulatory standards.
Develop and implement proactive strategies and methods necessary for a high performance culture related to quality, utilization management, and infection control.
Maintain current information on national, state, regional, and local regulations that impact accreditation and compliance. (Joint Commission, CMS)
Provide oversight for hospital's compliance with Joint Commission Standards. Meet accreditation and compliance expectations that are reasonably within the span of control.
Oversee implementation of a critical event review and root cause analysis system that provides aggregated trended data for leadership's use as required.
Supervise peer review activities in conjunction with the CQO and Medical Staff Affairs office.
Orient Medical staff to Quality, Patient Safety, and Risk Management
Present quality data and initiatives to Medical Staff, leadership, and departments as necessary.
Directs day-to-day activities of quality, utilization management, and infection control staff.
Develops and oversees the implementation of policies and procedures for areas of responsibility.
Work with Medical Records on documentation and coding initiatives.
Directs hospital activities related to Quality, Utilization Review, and Infection Control Staff either directly or through staff. Successful programs recognized by external and internal audiences.
Develops an annual plan including operating metrics for dashboard.
Skillfully achieves positive results for the organization related to investigations of complaints.
Facilitates various organizational level meetings to include Board of Trustees, Medical Board, and other hospital committees in conjunction with Chief Medical Officer, as requested.
Available for one-on-one meetings with a wide range of stakeholders for education/development and problem-solving.
Provides major educational offerings on new tools, techniques and approaches to a wide variety of audiences as appropriate.
Represent THA with outside contingencies on matters of quality.
Act as a designated lead for quality and risk matters in the absence of the Chief Medical Officer.
Service:
Customer Service:
Timely follow through and response to issues or complaints (i.e. SALT investigations completed within 30 days, patient complaints addressed during hospital stay or within 24 hours post discharge, and CMS 7 day requirement is met).
Develop and maintain effective relationships with internal and external clients.
Ongoing education of staff on service expectations, including service recovery.
Effective use of Leader Listening Rounds to proactively identify and resolve potential issues.
Achieves and maintains high levels of internal and external customer satisfaction.
Patient Satisfaction:
Patient satisfaction indicators have been met.
Review Press Ganey patient satisfaction data to determine trends and develop/implement action plans to ensure high levels of satisfaction are maintained.
Quality and Performance Improvement:
Department Specific:
Participates in the data collection and analysis of clinical and financial data (i.e. LOS data, avoidable days, adverse determinations, denials/appeals) and makes recommendations to improve performance.
Effectively utilizes national best practices and benchmarking sources in support of top level performance by THA for core measures and pay-for-performance metrics with evidence of utilization in work products.
Analyzes trends of events related patient safety and risk reduction issues to develop/implement process improvements as needed.
Hospital Based:
Understand basic core measure standards and be able to describe how these measures relate to our strategic objectives.
Develop a plan for incorporating core measure compliance into daily workflow.
Develop a plan for educating, measuring, monitoring, and improving performance on the patient safety KPIs, including hand hygiene, patient identifiers, and timeouts if applicable.
Create a mechanism for continuous quality improvement on the individual unit, to include at least one focused project per year in an area of need identified by the unit.
Tier 2 observations with monthly reporting as applicable.
Financial Operations:
Volume targets have been met.
Revenue targets have been met.
Expense targets have been met.
Invoices processed in a timely manner.
Labor productivity at 95% or above
Overtime and call back targets have been met.
Develops, monitors, adjusts and explains variances for operational and capital budgets for areas of responsibility.
Manage the approved budget through frequent and regular monitoring, implementation of effective written action plans to address variances, and implementation and adjusting strategies as needed to meet budgetary expectations.
Human Resource Management:
Timely completion of employee reviews.
Retention indicators have been met.
All mandatory training for staff completed.
Initial and annual competency assessment of staff completed timely.
Annual employee health screening of staff completed.
Ensure that all employees maintain current licensure, certification, and registry as required by their job.
Vacancy rate indicators have been met.
Employee engagement survey participation goals have been met.
Department engagement/partnership goals have been met and action plans have been completed.
Employee engagement results for direct management meet established targets.
Recognition of employees through Applause and Shining Star Programs.
Ensure staff compliance with hospital and system policies.
Ongoing monitoring and management of staff performance using the disciplinary process as appropriate.
Promote professional growth, development and accountability in staff.
Identify leadership talent and actively develop leadership skills for future opportunities.
Oversees the effectiveness of the department recruitment and retention program, taking action as necessary to provide an adequate level of qualified staff.
Professional Accountability:
Participates in hospital initiatives (i.e. fund raising events and community events)
Serves on hospital and system based committees as appropriate
Maintains current licensure and certification as required by position.
Adheres to hospital and system policies.
Completes mandatory training and annual employee health screening timely.
Recognizes and communicates ethical and legal concerns through the established channels of communication.
Maintains professional growth and development through seminars, workshops, and professional affiliations.
Demonstrates accountability and responsibility by independently completing projects/assignments on time and providing timely responses to requests for information.
Maintains confidentiality at all times.
Performs other work as requested that is reasonably related to the employee's position, qualifications, and competencies.
Entity Information:
Texas Health Presbyterian Hospital Allen is a 73-bed, acute-care hospital serving the northern Collin County area since 2000. Hospital services include women's care, a Level II neonatal intensive care unit, orthopedics, pediatrics, wound care and sleep medicine. Texas Health Allen, a Pathway to Excellence┬ designated hospital by the American Nurses Credentialing Center, has more than 500 physicians on its medical staff practicing in more than 25 specialties. Texas Health Allen is a World Health Organization-designated "Baby-Friendly Hospital" and was the first hospital in Texas to receive the distinction. The hospital is a Level IV trauma center and an Accredited Chest Pain Center by the Society of Chest Pain Centers, which makes our facility intensely qualified to serve our community and your professional aspirations.

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