Director, Quality and 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

Day (United States of America)

Job Summary:

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:

Results-Oriented Leadership of Quality Services
* Oversees the development and implementation of the hospitals Performance Improvement Plan in accordance with regulatory requirements, in response to hospital improvement opportunities, and in coordination with the WellStar strategic plan and goals
* Assists hospital departments in the development of their Quality Assurance Performance Improvement (QAPI) goals and action plans. Ensures departments provide routine reporting of progress.
* Conducts an annual assessment of the hospital PI Plan, providing a written report, and revising the plan as indicated
* Collaborates with Hospital and System Leadership to align priorities and resources with hospital and system goals
* Plans, implements and provides appropriate support for key clinical quality and safety initiatives
* Provides strategic direction and guidance on quality, safety and accreditation to operational leaders and timelines for new guidelines, regulations and processes
* Ensures adherence to Standard Work applicable to the roles and responsibilities within the department, as designed by the hospital and/or system.
* Effectively utilizes and collaborates with the corporate Enterprise Intelligence and Public Reporting teams on the analysis, interpretation and communication of publicly reported quality measures
* Monitors clinical and performance outcomes via benchmark analysis and facilitates accountability via defined expectations and goals
* Develops area-specific strategic plans and works with managers to facilitate goal achievement
* Facilitates standardization and prioritization of operations to achieve hospital objectives while assuring continuous quality improvement and outcome excellence
Patient Safety Officer Duties
* Serves as hospital Patient Safety Officer, providing oversight of comprehensive patient safety program
* Collaborates with System Leadership to implement and evaluate the Safety First Program in