Market Director of Quality, Regulatory, Risk, Patient Safety - Palm Coast, United States - AdventHealth

Description

**AdventHealth 60 Memorial Medical Parkway, Palm Coast, FL 32164**

**All the benefits and perks you need for you and your family:**

**Benefits & Paid Days Off from Day One**

**-** **Whole Person Wellbeing Resources**

**-** **Career Growth and Advancement Potential**

**Our promise to you:**

Joining AdventHealth is about being part of something bigger. Its about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that **together** we are even better.

**Shift** : FT Days

**The role youll contribute:**

The Market Director of Clinical Improvement & Risk Management / Patient Safety Officer provides leadership, direction and support for patient safety initiatives for the Central Florida Division North Region and the Flagler Market hospitals (Palm Coast and Palm Coast Parkway) responsibility includes Risk Management, Quality, Infection Prevention, Physician Peer Review, Just Culture, Patient Safety Organization, Data Analytics, Performance Improvement and Accreditation. The scope of work includes establishing policies, procedures, strategies and objectives specific to assigned departments for the region. Act as a liaison to the Medical Staff, Administration, all hospital Departments and committees to accomplish performance improvement and evidence-based practice initiatives. Responsibilities include the assurance that the regulations of applicable Federal, State, and local regulatory and accrediting agencies and the Corporate Compliance Plan are adhered to.

**The value youll bring to the team:**

**PRINCIPAL DUTIES AND JOB RESPONSIBILITIES** **:**

**SERVICE:**

Able to maintain credibility when communicating adverse news, follow through on promises and concerns, provide service recovery to dissatisfied customers, care about people as individuals and demonstrate empathy and concern while assuring that the organizational goals are met, accomplish objectives through influence, celebrate successes and accomplishments, and communicate a shared vision for the organization.

Interact collaboratively with Administration, Medical Staff, Nursing and Ancillary Departments to promote a culture that encourages concurrent quality improvement and safety.

Serves as Medical Staff liaison. Establishes and maintains productive working relationships with medical staff. Works in partnership with medical staff officers and chairmen to maximize committee performance. Ensures timely and relevant communication to all physician stakeholders.

Ensures new employees and medical staff members are oriented in Quality Improvement, Infection Prevention, Risk Management, Just Culture, Accreditation and Patient Safety

Fosters an environment of service excellence for patients, families, physicians and community

Provide local oversight and support to region corporate responsibility through monitoring and audit plans

Models shared-decision making in order to build collaborative relationships with executives, department directors, Board members, and the medical staff

Serves as a resource to the executive team and other departments for Patient Safety Initiatives, Performance Improvement, and Just Culture. Educates senior leadership teams in relation to patient safety and quality

**CLINICAL:**

Understands, articulates, and maintains accountability for organization risk management, infection prevention, quality assurance, performance improvement, and patient safety programs and plans in compliance with accrediting body standards, CMS Conditions of Participation, AHCA, and Florida State Statutes.

Drive strategies to improve the outcomes as measured by CMS Value Based Purchasing Plan, CMS Star Ratings, Leapfrog Safety Grade and other publicly reported data.

Facilitate the implementation of the organizational PI plan, ensuring universal participation and progress. Oversees committee and team meetings relevant to performance improvement and evidence-based practice. Directs data collection, analysis, bench marking and related utilization of information systems to achieve quality initiatives.

Directs and provides oversight for the activities of the Patient Safety/Ethics, Clinical Best Practice, Performance Improvement, Infection Prevention, and Medical Review committees

Oversees the monitoring of opportunities for infection prevention and ensures staff are educated on policies and prevention guidelines

Reports to the Board on performance improvement activities, risk management trends, risk reduction strategies to reduce patient harm, safety culture plans with goals, and publicly reported data with plans to improve.

Accountable to executives and the Board for contract assessment and reporting

Monitors and assures direct data analysis, trends, and review are compliant and timely

Oversight to physician peer review program and MRC

Ensure AHCA annual report is completed and submitted timely

Support patient safety organization and ensure data is submitted accurately and timely

**FINANCE:**

Consider the financial implications, safety implications, and clinical outcomes when making recommendations, evaluating technology and products, and developing policies and procedures

Incorporate fiscal assessments into program evaluations and/ or reports

Communicate resource needs to key stakeholders based on the goals and objectives of the programs.

Develops and implements annual budget. Monitors and makes adjustments to meet effective use of budgeted resources and maintain fiscal accountability.

**** Maintain compliance with departmental budget

**LEADERSHIP:**

Serves as Patient Safety Officer for the facilities.

Administrative oversight of the interview and selection process of new employees for the local Office of Clinical Effectiveness and Risk Management departments. Supervises the department leaders, performing employee performance evaluations as required, documenting employee performance and performing coaching and counseling as needed.

Active in the governance of the organization by presenting patient safety issues to the governing body, participating in strategic planning, and representing the local Office of Clinical Effectiveness at the organizations governing body.

Provides administrative supervision to achieve and maintain ongoing accreditations compliance / TJC readiness.

Delegates assignments and maintains accountability to achieve and maintain accreditation and quality-based certifications

Directs activities to ensure data bases for accreditation, patient safety and quality are maintained, accurate and current

**DEVELOPMENT:**

Attends 75% of the role-specific region council meetings

Completing a competency self-assessment with a professional development plan at least yearly

Maintaining current knowledge through the review of best practices, evidence-based research, consensus, and guidelines

Actively participating in professional organizations, both nationally and locally

Maintaining current knowledge through the review of best practices, evidence-based research, consensus, and guidelines.

Qualifications

**KNOWLEDGE AND SKILLS REQUIRED:**

Knowledge of legal aspects of healthcare, medical staff issues and performance improvement principles

Advanced knowledge of regulatory guidelines

Expert interpretation of raw data and comparative analysis

Exceptional communication skills including the ability to influence in a collaborative manner

Ability to work with data that is sensitive and confidential

Ability to influence and persuade teams, up to and including the executive level, to build consensus within and across stakeholder groups (high level negotiation skills)

Knowledge of regulatory (TJC/CMS/AHCA) standards/survey processes with the ability to integrate regulatory requirements into daily activities, learning and the development of the quality assurance, performance improvement and patient safety plans

English-language proficient with effective writing, listening, speaking/teaching communication skills

Mastery of performance improvement methodology and tools.

Analytical and managerial ability; motivational and team building skills.

Excellent computer skills including quality databases and Microsoft Office products

**_KNOWLEDGE AND SKILLS PREFERRED:_**

Facilitation of various PI methodologies (Six Sigma, Lean, PDSA, etc.)

Knowledge of advanced statistical methods and tools

**EDUCATION AND EXPERIENCE REQUIRED:**

Graduate of a School of Nursing

Bachelors degree in healthcare related field OR 10 years experience in clinical healthcare setting

Minimum five years healthcare management experience and minimum three years experience in Quality, Compliance, Risk or Patient Safety

**_EDUCATION AND EXPERIENCE PREFERRED:_**

Masters degree in healthcare related field

**LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED:**

Current Florida Registered Nurse License

**_LICENSURE, CERTIFICATION OR REGISTRATION PREFERRED:_**

Certified Professional in Patient Safety (CPPS)

Certified Professional in Healthcare Risk Manager (CPHRM)

Certified Professional in Healthcare Quality (CPHQ)

Six Sigma Performance Improvement Certification

Lean Performance Improvement Certification

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location.

**Category:** Quality/Clinical Effectiveness

**Organization:** AdventHealth Palm Coast

**Schedule:** Full-time

**Shift:** 1 - Day

**Req ID:**

We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.