- Provides a comprehensive assessment of organizational needs to identify strategies to improve patient safety and clinical outcomes and serves as a leader in the on-going advancement of a "Just Culture" that promotes the non-punitive reporting of patient safety concerns
- Develops and assists others in developing action plans for process improvement and ensures follow through and loop closure on these plans
- Works in collaboration with the Physician Chairs, Nursing Directors, Executive Director Quality, CMO, CQO and Quality & Patient Safety Committee and any others to evaluate the effectiveness and appropriateness of care and development of policies and procedure
- Facilitates identification and documentation of hospital-based approved performance improvement variances and complications
- Analyzes Vizient and other program identified mortality and complications data on a regular basis to identify areas for improvement, education, and safety improvement activities
- Develops and coordinates of projects that will enhance the Performance Improvement, Peer Review, and Patient Safety Program
- Leads the accreditation program in furtherance of continual Joint Commission readiness for the organization.
- Keeps informed of the Joint Commission requirements for triennial accreditation standards for Performance Improvement and OPPE/FPPE standards
- Completes case reviews and analyses for contributing factors to the variance in care and/or complications including all Serious Safety Events, deaths and complications.
- Facilitates the creation of physician-department Performance Improvement Committees and assists in preparing case reviews and projects for discussions
- Facilitates the semi-annual Leapfrog Safety Survey completion and all improvement activities surrounding this survey and any other publicly reported quality and patient safety data.
- Leads the investigation of all sentinel incidents (to include performing a root cause analysis)
- Develops ongoing physician practice evaluation triggers
- Generates annual report information regarding activities and prepares statistical data
- Supports the Medical Staff departments in identifying and selecting opportunities for improvement and facilitates continuous performance improvement
- Facilitates Medical Staff Peer Review meetings and serves as a liaison between various committees to facilitate communication and referral of cases for further physician review, and report results back to referring committee
- Attends safety huddle to report any safety trends found in chart review
- Maintains compliance with all company policies, procedures and standards of conduct
- Complies with HIPAA privacy and security requirements to maintain confidentiality at all times
- Performs other duties as assigned
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Director Quality and Patient Safety, South Hospital - Shepherdsville, United States - University of Louisville Hospital
Description
OverviewWe are hiring at UofL Health – South Hospital
Location:
1903 W. Hebron Ln.
Shepherdsville, KY 40165
Shift :
Full time, 1st Shift
About Us:
UofL Health is investing in the health of Bullitt County, and the surrounding area with an expansion of UofL Health – Medical Center South to become an inpatient hospital – UofL Health – South Hospital.
South Hospital is expected to open in early 2024 and will add approximately 100,000 square feet of new space to the existing facility.
South Hospital will include a 10-bed intensive care unit, medical/surgical patient rooms, six operating rooms, new cardiac catheterization lab, expanded emergency department, centralized sterile processing area, laboratory, pharmacy, cardiopulmonary, respiratory therapy and more.
Benefits and Perks:
Competitive Pay & Benefits Options.
Paid Vacation, Sick days, and Holidays.
Free tuition to UofL for Part- and Full-time employees for Child/Spouse/Domestic Partner.
401K with Employer Match.
Responsibilities
Job Summary:
Develops, operationalizes, maintains, and evaluates the Quality, Patient Safety, Clinical Performance Improvement, and Accreditation Program
Required Qualifications:
Bachelor of Science in Nursing
Minimum five years of acute care, hospital-based clinical experience in area of intended practice.
Preferred Qualifications:
Previous experience in academic teaching hospital
Master of Science in Nursing or other healthcare related master's degree
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