Director of Quality Safety and Staff Development - Gilchrist

The Director of Quality, Patient Safety, and Staff Development-Gilchrist, assists in the development and implementation of quality, patient safety, and accreditation standards. This role will also assist with assessing and identifying the training needs of clinical staff, and working in collaboration with the Senior Leadership, develop and deliver education, coaching, and training for clinical staff to ensure safety and compliance standards. This role will also monitor, review, and stay abreast of changes within regulatory rules and change within the appropriate accreditation organization, as well as federal, state and local government regulations that impact end of life care. The Director will provide leadership and work directly with managers, providers and staff to foster clinical effectiveness and quality outcomes and advance a culture of excellence throughout the organization.

Education:

Bachelor’s degree in business, nursing, or a health-related field; Master’s degree preferred. 

Patient safety training or certification preferred

Experience

Five years of progressive experience in healthcare quality, compliance, and patient safety with focus on end-of-life care   

Experience in leading Joint Commission and/or CHAP accreditation and CMS Surveys in post-acute settings, hospice and end of life preferred. Knowledge and experience with value-based purchasing models, as related to hospice and end of life.

Demonstrated experience using performance improvement skills such as Lean or Six Sigma and experience conducting

Licensures, Certifications

Current registration with the Maryland State Board of Examiners of Nurses as a Registered Nurse, or other advanced clinical license

Knowledge, Skills and Abilities

• Ability to identify system failures and facilitate changes that will lead to improvement
• Expert skill in oral and written communication, including demonstrated facilitation skills with diverse groups
• Performance improvement skills including root cause analysis and model for improvement
• Skill in managing multiple priorities and demonstrated ability to meet deadlines under all types of circumstances
• Strong clinical analysis and investigative skills necessary to assess patient safety occurrences, risk events and variances in clinical quality outcomes.
• Strong leadership and management and group facilitation skills.
• Ability to influence and negotiate individual and group decision-making.
• Advanced interpersonal skills to manage, direct, and coordinate the activities of multiple departments to positively communicate and work with professionals at all levels of the organization
• Ability to manage circumstances where uncertainty is inherent.
• Mentoring and coaching management-level staff by providing open and honest feedback that results in enhanced performance outcomes.
• Skilled communicator and expert in facilitating safety events such as RCA, FMEA, and other root cause and effect tools.
• Mentors and drives engagement with direct reports and department leaders in individual areas of oversight using the organization’s Leadership System.
• Ability to read, interpret and apply regulatory and accreditation requirements.  Solid understanding of CMS, CoPs,  and CHAP standards.
• Technical skills include comfort and familiarity with Microsoft Office programs and ability to assemble and analyze data for meaningful results.
• Projects and role models a professional image at all times in both action and presence.

Principal Duties and Responsibilities

• Oversees the organization’s quality and patient safety program. Works collaboratively with senior leaders, clinicians and others throughout the organization to guide systems improvement that supports the achievement of assigned strategic initiatives.  Provides direction and counsel to identify and resolve variances in clinical quality outcomes, accreditation requirements and processes related to patient safety and risk management
• Oversees the data collection and reporting of all external clinical quality outcomes.  Ensures data submissions are accurate and timely.  Provides clinical leadership to direct reports and others in the organization necessary to guide improvement to achieve strategic objectives.
• Oversees timely follow-up and corrective actions completed within the department related to safety events, accreditation and regulatory surveys and other improvement activities. 
• Oversees the process for root cause analysis for Level 1 and Level 2 events and Level 3 events as appropriate to ensure system failures are identified and corrective actions are implemented.  Completes reports as required for the OHCQ or other regulatory body.
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