Department: Medical Quality ManagementAssists the Vice President Medical Affairs (VPMA) and Regional Director of Quality and Safety with the development and implementation of the Hospital-wide Performance Improvement and Risk Management Programs consistent with board approved plans and regulatory and standard setting agencies
- Reports to the Vice President of Medical Affairs
Bachelor of Science in Health Care related field, Masters or JD preferred.Minimum Experience:
- Three to five years experience within a healthcare setting with a focus on patient safety, risk management or quality improvement.
- Experience and/or demonstrated understanding of root cause analysis and FMEA analysis.
- Experience in statistical analysis tools.
- Strong organizational skills.
- Strong interpersonal skills, ability to work across disciplines.
- Ability to analyze data, formulate meaningful information.
- Ability to work with, develop, motivate multi-disciplinary CQI Teams.
- Strong orientation to patient care in accordance with the Medical Center's values, particularly the holistic approach to healing.
- Ability to work with highly sensitive and confidential information with appropriate discretion.
- Able to communicate verbally and in writing in the English language.
- Strong computer and database skills
ASHRM or CPHQ designation preferred
Training: Training in patient safety or risk management and quality/performance Improvement methodology, concepts, education and implementation.Special Qualifications:
- Membership and active participation in professional organization(s).
- Provides superior customer service to internal and external clients, customers, and patients as referenced in the Service Excellence Standards.
- Provides administrative support for the Quality and Safety Committee, Patient Safety Triage Team, Performance Improvement Task Forces and other related committees
- Attends departmental/hospital meetings where measurement and evaluation functions and quality management activities are performed, as agreed upon by the VPMA,Chairman of the committee or the Director of Service.
- Attends Performance Improvement Task Force meetings and Collaborative Group Practice meetings where performance improvement activities are conducted.
- Assists with the annual evaluation of the Performance Improvement Plan and Program, on behalf of the Performance Improvement Council. Assists with follow-up of patient safety and risk issues addressed by the Quality and Safety Committee.
- Assists departments with the development, implementation of hospital tracking system for quality and risk management issues. Orients personnel to required use.
- Assists departments with the integration of quality and risk management activities.
- Reviews departmental quality indicators for compliance, appropriateness and rationale.
- Reviews and analyzes incident reports, rates by severity and conducts all follow-up as identified from review.
- Completes trending analysis to identify top priority areas for improvement.
- Conducts root cause analysis in the event of a sentinel or near miss event.
- Coordinates review of medical information, debriefs all individuals as identified, performs cause and effect analysis and coordinates expert panel review, root solution and follow-up for all incidents identified.
- Conducts FMEA analysis when high volume, high risk opportunities are discovered through incident report analysis.
- Organizes team, creates process maps, creates failure modes analysis, and identifies prevention and/or corrective action strategies and implants as identified.
- Assists the VPMA with appropriate reporting of risk events to regulatory agencies and insurance carrier.
- Understanding and implementation of programs related to national and local patient safety initiatives.
- Acts as liaison to statewide and national collaborative for quality and safety initiatives.
- Available on beeper at all times during scheduled working hours.
- Performs all other job related duties as requested by the Director of Quality and Safety.