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    Market Director, Quality - Tyler, United States - UT Health East Texas Market

    UT Health East Texas Market
    UT Health East Texas Market Tyler, United States

    3 weeks ago

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    Description

    Overview:
    Join our UT Health East Texas team as a Director of Quality & Patient Safety

    In a joint venture partnership with UT Health System, Ardent operates UT Health East Texas in Tyler, Texas. UT Health East Texas is comprised of UT Health Tyler

    (the areas only Level I trauma center), UT Health North Campus, UT Health Athens, UT Health Carthage, UT Health Henderson, UT Health Jacksonville, UT Health

    Pittsburg, UT Health Quitman, UT Health Air1/EMS, UT Health East Texas Rehabilitation Hospital, UT Health Long Term Acute Care, UT Health Hope Cancer Center

    and UT Health East Texas Physicians. With 974 licensed beds, UT Health East Texas is advancing healthcare, together.


    POSITION SUMMARY
    The position of

    Quality and

    Patient

    Safety

    Director

    at
    UTHETis accountable for

    assisting


    the organization to improve quality, safety, and reduce operational risk exposure through performance improvement processes and meeting regulatory and accreditation requirements.

    They will

    assist

    in the implementation of UTHETs Quality/Clinical effectiveness function. This position supports a culture of high reliability and the measurement of care quality

    identifying

    opportunities and executing on strategies for performance improvement in the following areas of the organization:
    Outcomes -

    highly reliable

    processes, deli

    vering exceptional outcomes and/

    or

    optimal

    health
    Safety

    Deliver the safest care to patients driven through leadership and a culture of high reliabilit

    y
    Accreditation-Ensures all regulatory requirements are managed and highly functional
    Experience of Care - relationship-centered care grounded in empathy, dignity,

    respect

    and collaboration


    Responsibilities:
    Support a proactive, comprehensive strategic Quality agenda that inspires caregiver engagement, inter-professional collaboration, the iden

    tification and use of evidence-

    based practice and management among all entities in the system while differentiating


    UTHET
    as a high reliability organization nationally.

    Provides

    accurate

    and meaningful data to teams,

    committees

    and physician groups by understanding data dictionaries and using appropriately, using self-coded data sheets,

    assisting

    in determining

    appropriate data

    to collect by asking right questions and

    identifying

    correct populations, and using working knowledge of existing databases to obtain data already being collected.

    Appropriate knowledge and application of basic statistical tools, such as, standard deviation, frequency distributions, histograms, and

    Pareto charts

    .
    Actively

    participate

    in divisional meetings, processes, and activities to ensure Quality functions are

    disseminated

    consistently throughout the division.
    Chair and lead the local Performance Improvement Committee

    .
    Acts as a liaison between the Performance Improvement Committee and the Governing Board, to ensure all CMS

    CoPs

    are met.

    Applies quality improvement methodologies as a quality representative/facilitator for PI Teams and as a consultant to provide basic CQI or statistical tools.

    Evaluates and makes recommendations for system improvements using quality data,

    event

    and regulatory compliance reports.
    Provides project management to assigned teams by providing leadership to focus areas and by

    utilizing

    facilitation and assessment skills to develop evidence-based initiatives.

    Regulatory Compliance:
    Drives all regulatory functions on the local level.
    Applies a current working knowledge of regulatory compliance standards as

    appropriate to

    assignment or specialty.
    Participates in all divisional regulatory functions and standards.
    Leads the participation and management of the Internal Quality Survey process, including

    timely

    and

    appropriate response

    to action plans.
    Lead and drive the sustainability efforts for all IQS and TJC action plans to ensure compliance is

    maintained

    and practice changes are hardwired

    .
    Provides advanced consultation and support by collaborating with

    peers


    throughout the corporation to develop methods and plans to meet standards, participating in the writing or development of new policies, procedures and guidelines, researching literature and outside sources to identify new methods, technologies, or approaches for compliance, ensuring compliance to regulatory support and assessing compliance to standards to ensure a safe and consistent care environment to multiple areas and settings.


    Patient Safety:

    Leads Mission Zero:
    Our Cultur

    e of Safety on the local level, based on division standards and expectations.
    Leads and/or functions as the

    Risk Manager on the local level, based on division standards and expectations.
    Applies a current working knowledge of national, local, and system patient safety standards and trends as

    appropriate to

    assignment or specialty.
    Leads PSEA and RCA efforts and reports to the Ardent PSO, per requirements.
    Participates in the division SENT process for reporting safety events.
    Participates in the division safety event classification process.
    Provides collaboration and consultative support to Risk Management, Compliance, Medical Staff, Nursing, and others by compiling reports with recommendations from

    appropriate sources

    ,

    participating

    in maintenance of applicable Safety Plans, networking across departments and facilities to achieve

    objectives

    and goals,

    participate


    or facilitate patient safety improvement teams, and engages and interacts with staff at all levels to encourage ownership of initiatives.


    Practice Standardization and Policies:
    Advocate and support standardization by educating focus areas to centrally developed policies, procedures, processes, and forms and assisting/

    participating

    in corporate teams with the development of policies, procedures, processes, and forms.
    Participate in development, implementation, revision, and review of policy, procedures, protocol, guidelines, and forms, when

    appropriate for

    focus areas.

    Education:
    Provides education to focus areas

    regarding

    Quality Monitoring and Improvement, Regulatory Compliance, Patient Safety,

    Risk Management, Medical Staff Services

    and Practice Standardization and Policies.

    Informatics, Data and Analytics:
    Support quality measurements for internal use.

    Support and distribute standardized reports that are developed centrally to ensure consistency in data management and reporting across the division.

    Support the deployment and optimization of the electronic health record to maximize safety, quality outcomes, clinical

    effectiveness

    and efficiency.
    Advance, with others, the use of predictive analytics and deep learning computing to improve the health,

    experience

    and quality of care of those we serve.?

    SUPERVISION:
    Depending on

    the

    facility, the director may

    be responsible for

    3-5 direct reports.


    Qualifications:
    Education & Experience

    Required:
    Bachelor's degree in Business

    , Healthcare Administration, Public Health or other

    business related

    field. Education must be obtained through an accredited institution and will be verified.

    Experience with change management with the ability to provide leadership in the adaptation and implementation of new processes and /or technology that enhance Quality.

    E

    xperience overseeing patient safety programs

    .
    E

    xperience leading teams

    .
    E

    xperie

    nce leading successful Quality I

    mprovement projects

    .
    One of the following certifications is preferred-CPHQ, CPXP, CPSP, CPHRM
    Experience working in a complex health system (hospitals, ambulatory clinics, post-acute care, etc.)
    Experience with external entities that drive and support Quality approaches and standards, including government agencies, academic institutions, universities and related organizations of higher education, and other public institutions is preferred
    Knowledge, Skills & Abilities
    Effective verbal, written and interpersonal communication skills.
    Trained in improvement science (i.e., Six Sigma, Lean, UT System CSE or DMAIC)

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