Senior Clinical Director, Perioperative Safety, Quality and Compliance

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

The Executive Director, Perioperative Safety, Quality and Compliance, reporting to the Senior Vice President of Perioperative Services with a secondary reporting relationship to the SVP Patient Care Services and CNO. This individual is key in connecting all aspects of Perioperative Safety, Quality and Compliance in support of BIDMC’s mission to provide extraordinary high-quality care, where the patient comes first in an environment which preventable harm is minimized. The sphere of influence of this leader has a primary focus of perioperative services. This focus includes patients, families and employees. This leader actively engages in implementing the Leadership goals of Perioperative Services and BIDMC.

Job Description:

Essential Responsibilities

Clinical responsibilities

• The Executive Director, of Safety, Quality and Compliance along with the Senior Vice President of Perioperative Services creates a dyad that links the Surgical Division’s Chiefs, Quality Directors, Nurse Leaders, Associate Chief Nurses, Directors, Managers, and Healthcare quality colleagues involved in the care of patients, families and employees in the perioperative environment
• Role model for culture of safety and quality within Perioperative Services. This individual is responsible for creating, coordination and facilitation of activities across all perioperative divisions including but not limited to Orthopedics, OB-GYN, Department of Surgery, Anesthesia and Perioperative PCS 
• This individual works directly with the Director of Patient Safety to facilitate the timely review, response and sustained compliance of action plans
• Creation of a Perioperative QI forum, a peer-review protected committee convened under the authority of the respective chiefs meeting monthly to provide and engage in a multidisciplinary review of safety and quality concerns across the division.  The Director will report to QI Directors the findings of this forum.
• Serve as the Co-Chair of the Perioperative Safety and Quality Care Committee facilitates and coordinates all of its activities. Provides a forum to openly discuss risk and to proactively develop strategies to prevent harm
• Facilitates and organizes the demands of quality, safety, compliance and engagement in order to focus on not only the daily demands, but also to facilitate situational readiness in a strategic proactive manner.
• Utilization of root cause analysis and action, and cause mapping models for comprehensive review of safety events within periop, facilitate corrective action planning, and develop necessary education and staff development and training needs.  Safety events can include but are not limited to patient harm, surgical events, diagnostic/treatment related events, non-harm related events, product performance concerns and recalls and threats to safety of employees
• Actively utilizes the tools of Job Safety Behavioral Observation (JSBO) to minimize employee injuries in compliance with OSHA guidelines and requirements
• Works with local leaders to follow-up on practice alerts, their impact and sustaining rolled out processes

Global Responsibilities

• Balances priorities of quality, safety and help to remove barriers to positive employee engagement, operational excellence and strategic alignment to improve patient care and reduce psychological tension
• Maintains active participation in QI Directors, Safety, Quality Oversight Committee, OREC, TJC, Peer Support, and Emergency Management, Q & S Ops
• Conducts risk and safety assessment and mitigation both in ongoing daily activities and as a strategic initiative related to structured scheduled surveys
• Presentation of Quality, Safety and Compliance data for perioperative services in quality and safety forms within internally and externally.

Quality and Safety Goals:

• Collaborates with Quality and Safety leaders through BIDMC so that Perioperative Services is positioned in a coordinated and comprehensive way for the quality, safety and compliance culture across BIDMC.
• To actively engage in policy development, review and updating to ensure policies are consistent with evidence based practice and completed in a timely manner
• Works in collaboration with Perioperative Performance Management Director and other perioperative leaders on development, support, and facilitation of measurable key performance indicators (KPIs) for perioperative services related to strategic BIDMC priorities. Identify opportunities for improvement and to responds to patient/family survey data and works to improve satisfaction scores
•  Primary contribution in this area will be to serve a clinica