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Associate Director of Quality Management & Patient Safety

Galveston, Texas, United States

New

Executive - Nursing & Patient Care

UTMB Health

Requisition # 2502806

Job Summary:

The Associate Director of Quality Management & Patient Safety leads, develops, implements, and facilitates health system and hospital clinical activities, as well as collaboratives to achieve the best quality outcomes and prevent adverse events across the continuum of care. This position will provide UTMB Health with technical and implementation leadership support, including consults, training/education, and assistance prioritizing quality/safety strategies and actions. This position includes on-site visits and consultations at all campuses and ambulatory sites as needed.

The Associate Director facilitates the integration of the strategic vision into clinical practice through collaboration with the local leaders and the support of the Director of Quality Management & Patient Safety. The Assistant Director is knowledgeable about the components of a patient safety culture and patient safety science. The incumbent utilizes this knowledge to advance quality and patient safety at the front lines of care delivery.

Scope:** **_The Associate Director of Quality Management & Patient Safety supports all campuses and health system activities, including federal, state, and local regulatory compliance across the UTMB network of hospitals and ambulatory services._

Responsibilities:

+ Assists the Director, Department of Quality and Healthcare Safety, in executing and advancing annual performance improvement plans, including supporting education, facilitating project team meetings, and developing communications.

+ Facilitates and participates in developing and implementing assigned new initiatives, programs, services, and relationships to improve clinical and operational performance, enhance services and outcomes, and enhance margins using a disciplined, team-based design and rapid cycle improvement methods.

+ Performs analysis of various aspects of operations, tracks initiative progress, monitors evaluative measures, and reports accordingly.

+ Performs critical reviews of published reports and identifies best-performing practices related to target processes to facilitate evidence-based practice and management.

+ Works collaboratively with hospital leadership to develop plans to address annual patient safety and PI priorities and align them with UTMB quality and safety plans/priorities.

+ Facilitates/participates in and may lead collaborative interdepartmental approaches to develop and enhance an integrated care system, including data management and methods and tools (e.g., PDSA, lean, causal reviews, FMEA, etc.).

+ Works with the UTMB Quality Director to establish, implement, and monitor service level agreements, department performance standards, and appropriate use of organizational resources.

+ Assists with complaint responses from various organizations in collaboration with clinical departments involved in patient care.

+ Assists with recruitment, retention, development, and ongoing management of assigned staff.

+ Prepares reports as requested by the Chief Medical Officer, Hospital Leader(s), Community Hospital Leader(s), and the UTMB Director of Quality and Safety.

+ Serves as liaison between UTMB Department of Quality and Healthcare Safety, departments, and local groups to facilitate collaborative programs.

+ Ensures adherence to internal controls and reporting structure.

+ Disciplined change management and performance improvement techniques.

+ Principles and practices of supervision and administration as applied to the management and direction of personnel within areas of accountability.

+ Effective managerial and administrative abilities as applied to the complex environment of an academic health system, including community hospitals and ambulatory service centers.

+ Self-starter in developing and analyzing options and recommending solutions.

+ Effectively deal with conflict management and have the skill to anticipate and bring issues to resolution.

+ Strong interpersonal skills with high professionalism and diplomacy in dealing with the staff at all institution levels and external agencies.

+ Effective verbal, written, and interpersonal communication and practical presentation skills.

+ Performs related duties as required.

Quality/Performance Improvement

+ Leads quality, process, performance improvement, patient safety activities, and accreditation within assigned areas(s).

+ Facilitates Performance Improvement activities and supports department leaders in conducting local improvements.

+ Oversees reporting Core Measures and value-based purchasing activities according to TJC and CMS timelines and guidelines.

+ Collaborates with operational leaders on organizational initiatives for each campus.

+ Leads teams responsible for reviews using specific indicators according to NQF and AHRQ criteria/specifications.

+ Works with staff to analyze outcomes, process measures, and benchmarks to identify improvement opportunities; works with individual departments and staff to address outcomes below expected benchmarks.

+ Partners with hospital leadership on the Culture of Safety Survey process, reviewing and analyzing the responses, reporting outcomes, assisting clinical areas with actions, and monitoring progress.

Patient Safety

+ Promotes a safety culture across the campus by providing education and support for front-line personnel, managers, directors, and physicians in event reporting and risk evaluation principles and practices, and by gathering, aggregating, and disseminating patient safety events and risk management data.

+ Uses event reporting data to identify opportunities for improvement and preventive measures related to Health System goals.

+ Work with campus personnel to integrate event reporting, management, dissemination, and management of potential adverse events (PAEs) and potentially compensable events.

+ Promotes a non-punitive culture for reporting adverse events and unsafe conditions using the organization's incident reporting system.

+ Monitors system trends and detailed data to identify safety concerns and opportunities for quality improvement.

+ Works collaboratively with Risk Management personnel to identify or escalate potentially compensable events and with the Quality Management Specialists to identify and report potentially adverse events (PAEs).

Accreditation

+ Works with the Assistant Director of Accreditation to manage Joint Commission accreditation's continual assessment and readiness at all community campus locations.

+ Coordinates educational efforts related to the Joint Commission, including National Patient Safety Goals.

+ Works with leadership, physicians, and department director groups to:

o Ensure a coordinated response to unannounced external accrediting or regulatory agency visits by managing the process and staff.

o Manages individual complaints or letters requesting information from accrediting agencies.

o Coordinates and oversees the establishment of mechanisms to correct areas of non-compliance with applicable standards.

o Maintains familiarity with all applicable accreditation standards, keeps abreast of changes, and communicates changes to leadership and chapter experts.

o Coordinates with the Director to complete an annual evaluation of accreditation compliance at each campus.

Knowledge/Skills/Abilities:

+ Principles and practices of supervision and administration as applied to the management and direction of personnel within areas of accountability.

+ Effective managerial and administrative abilities as applied to the complex environment of an academic health system, including community hospitals and ambulatory service centers.

+ Self-starter in developing and analyzing options and recommending solutions.

+ Effectively deal with conflict management and have the skill to anticipate and bring issues to resolution.

+ Strong interpersonal skills with high professionalism and diplomacy in dealing with the staff at all institution levels and external agencies.

+ The candidate will have experience working with performance improvement tools and methods, such as PDSA, LEAN techniques, and High-Reliability Organizations, and the ability to present actionable data for improvement projects.

+ Demonstrated success with program management.

+ Excellent leadership, communication, presentation skills, and the ability to influence.

Minimum Qualifications:

+ Bachelor's degree in nursing withcomprehensive knowledge of healthcare operations plus five (5) years of progressive responsibility, including clinical and quality management experience/process improvement/accreditation, or comparable experience.

+ Must possess and maintain a current RN license or valid temporary permit to practice in Texas.

Preferred Qualifications:

+ Master's degree in a clinical field, health management, or health-related field.

+ Specialty certification in quality, safety, or accreditation.

+ Project management and Lean experience are a plus.

+ Experience in clinical care settings across the continuum is preferred, allowing in-depth analysis of the care processes surrounding patients and families.

Equal Employment Opportunity

UTMB Health strives to provide equal opportunity employment without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, genetic information, disability, veteran status, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. As a Federal Contractor, UTMB Health takes affirmative action to hire and advance protected veterans and individuals with disabilities.

Compensation