Director, Quality, Safety and Emergency Preparedness

Description

POSITION SUMMARY

The Director of Quality, Safety, and Emergency Preparedness is responsible for fostering a trauma-informed and safety-conscious culture of excellence and continuous learning among clinical staff. This position will develop and conduct evaluations of patient care. These evaluations, aimed at promoting growth and non-violence, will be determined by the ongoing assessment of clinical staff competency, the evaluation of care provided, observation of the quality of clinical services, the assessment of staff's adherence to proper procedures and professional conduct, and the review of medical records and documentation. This position will work in shared governance and collaborate with practice managers, the Chief and Deputy Chief Operating Officers, and the Medical Directors to oversee overall clinical competence and organizational learning across all locations, ensuring a culture of inquiry and safety for both patients and staff.

REPORTING RELATIONSHIPS

This position reports directly to the Chief Medical Officer and the VP & Chief Compliance Officer The following positions report to this role Director Employee Health and CME Coordinator.

ESSENTIAL JOB DUTIES and FUNCTIONS

While living and demonstrating our Core Values, the Director of Quality, Safety and Emergency Preparedness will oversee and/or lead the following:

• Provide oversight and guidance to staff to maximize efficiency and productivity.
• Clarify job descriptions and hold staff accountable.
• Conduct semi-annual training in all clinical sites.
• Ensure QI/QA assessments are conducted on a regular basis.
• Continuously monitor QI/QA outcomes and report to Clinician Advisory Committee (CAC) on a monthly basis
• Oversee completion of management-approved direct observation tool (mini-CEX) per employee per month
• Directly observe the clinical skills for RNs, LPNs and MAs.  Monitor completion of staff competency assessments using direct observation tools and support continued education.  Collaborate with Managers to implement remediation plans for clinical staff who need improvement.
• Provide relevant and creative education for clinical staff on a variety of topics, focusing on development of clinical skills, interpersonal skills, and critical thinking.
• Participate in weekly clinical level 10 meetings and attend other necessary meetings.
• Provide clinical updates and policy changes to the Clinician Advisory, Community Health and GME Quality and Safety Committees 
• Participate as a voting member Graduate Medical Education Committee
• Participate in performance improvement activities.
• Develop, implement and oversee Quality and Safety Program for all clinical sites in accordance with NCQA, HRSA and other governing entities’ guidelines.
• Implement new clinical protocols to improve patient quality care and safety.
• Review and develop policy and procedures for all clinical sites
• In conjunction with Administrative Managers, lead the emergency preparedness plan in all clinical sites.
• Responsible for addressing patient safety-related SAFE reports and work on PDSAs/RCAs in conjunction with SAFE reports.
• Responsible for identifying staffing needs, position requirements, conducting interviews and recommending new employees in conjunction with Administrative Manager and Medical Directors.
• Conduct ongoing performance evaluations on staff which includes, but is not limited to, annual evaluations, performance improvement plans and disciplinary actions.
• Monitors compliance of staff with HIPAA, OSHA, PA DOH, and other policies and procedures of local, state and federal guidelines.
• Ensure all employees have current certifications and licensure in accordance with local, state, and federal regulations
• Design staff education to support Medical Home function
• Chair the Emergency Preparedness Committee to address emergency situations, including staffing and partnership outsourcing, environmental scanning, event reporting, and response management.
• Chair the Infection Control and Prevention Committee to provide leadership and direction to the Infection Control and Prevention Committee, ensuring the development, implementation, and monitoring of effective strategies to prevent and control healthcare-associated infections (HAIs) within The Wright Center. The Chair fosters a collaborative and proactive approach to infection prevention, promoting a culture of safety and continuous improvement. Lead the development and regular review of the organization's Infection Prevention and Control Plan, aligning it with current best practices, regulatory requirements, and organizational goals.
• Collaborate with the Credentialing Department to ensure Peer re