Executive Director, Quality & Safety

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

Work Shift

Job Summary:

The Executive Director of Quality and Safety is responsible for developing a vision and executable plan to attain world class quality and safety processes and procedures across the hospital and all hospital outpatient departments (HOD) and including any associated Health Parks. Accountable to ensure successful development and deployment of the WellStar Quality and Safety strategy in a manner that supports achievement of WellStar Quality goals. Bringing patient safety and clinical quality expertise, he/she will partner with leadership, staff and system partners to identify opportunities for short and long-term impact on quality and safety outcomes in alignment with WellStar's strategic plan.
Plans, organizes and directs all services and operations of the department which includes quality performance improvement, continuous survey readiness, and infection prevention programs for the hospital. Works collaboratively with hospital Vice Presidents, Directors and Managers, as well as system leadership and peers to align department goals with Hospital and System strategic goals. Oversees daily operations to ensure delivery of high quality services and support and execution of tactics designed to meet the goals. Is responsible for coordinating activities of Quality Committees with appropriate personnel, including medical staff Quality, PI and peer review committees. Ensures processes in support of accurate and high performing publicly reported quality data, WellStar quality goals and applicable data registries. Leads hospital implementation and ongoing support of Lean PI methodology.
Serves as an influential champion for the WellStar Safety First program, supporting a fair and just culture of safety, accountability and organizational learning. Works to effectively integrate functions and coordinate collaboration across the care continuum. Partners with external organizations to ensure regulatory and accreditation standards compliance and to infuse best practices into improvement efforts.
The individual in this role will proactively identify opportunities to optimize performance, build internal competencies, foster a strong and empowered team, and create a rigorous approach to quality and safety throughout the organization, with a strong focus on the patient, accountability and appropriate use of resources.

Core Responsibilities and Essential Functions:

Establishes, Oversees, and Executes the Quality and Reliability Program, including Patient Safety:
Provide centralized direction, governance and leadership for major projects and programs
related to Quality Performance and Patient Safety.
Develop and implement the long-term and short-term strategy for Safety and Quality.
Ensure governance level Quality reports and communications support the Board of Trustee and delegated Board committees to meet the fiduciary responsibilities.
Meet all regulatory & accreditation requirements with respect to periodic quality and safety related reports
Serve as liaison to all local level business units and entities for oversight and advising on quality
improvement projects and their alignment with system goals.
Responsible for managing quality improvement and infection control for the hospital and associated Health Parks.
Committee/Work Group Support: Chair and participate in quality committees coordinated/facilitated by the department, including Quality Review Committee, Infection Control Committee, Value Committee, Medication Safety, and/or Peer Review Committees.
Integrate other appropriate improvement and High Reliability strategies and tools. Provide advisory coaching and educational training on process improvement projects, methodology, tools, and standards.
Mitigates medical/legal liability through development of a program which links risk management activities with those of continuous performance improvement.
Contributes to the management of the accreditation, regulation, and licensing activities to include communicating the programs/processes to providers and medical staff, preparing of surveys and inspections, and completing assessments, response plans and measures of success.
Safety Event Management Program
Investigation of Alleged Quality of Care Incidents: Investigate quality of care incidents and near misses according to the department's establishe