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Eastern Region Director, Quality & Safety

Company: Trinity Health
Location: Dubuque
Posted on: January 23, 2023

Job Description:

Employment Type:Full timeShift:Day ShiftDescription:The Eastern Region Director of Quality & Safety is a member of the MercyOne Eastern Iowa Regional Executive Team. The purpose of the role is to lead quality and safety programming that consistently cultivate high standards and excellent outcomes in all dimensions of performance. In collaboration with the Regional Executive Team, establishes quality and safety structures that culminate in high reliability.The Eastern Region Director of Quality & Safety provides leadership in the development and implementation of performance excellence strategies related to clinical indicators, outcome measures, process improvement methodologies and services that ensure high quality, safe care. This role has accountability for the following departments/functions: Quality, Risk Management, Infection Prevention, Accreditation, performance excellence (LEAN), and culture of safety (TogetherSafe). In addition, the Director of Quality and Safety provides support and oversight for the medical staff services department.ESSENTIAL FUNCTIONS:

  • Knows, understands, incorporates and demonstrates the MercyOne (Trinity Health) Mission, Vision, Core Values, Actions and Promise in behaviors, practices, and decisions.
  • Provides leadership, strategic direction, guidance and oversight with respect to quality improvement and safety, infection prevention and risk management initiatives, performance excellence (LEAN), culture of safety (TogetherSafe) and accreditation readiness across the MercyOne Eastern Iowa region. Assesses effectiveness of all areas of responsibility and adjusts to ensure consistent operational effectiveness.
  • Fosters and cultivates a high reliability mindfulness focused on creating exceptionally safe and consistently high-quality care. Demonstrates a relentless pursuit of a culture of safety where zero harm is the highest priority.
  • Develops an overall performance improvement plan consistent with the strategic plan, and in conjunction with the Regional Executive Team, Senior Leadership Team of each market hospital, and quality improvement committees (QICs), the Medical Executive Committees, and the Board of Trustees/Directors.
  • Works strategically with the medical and nursing staffs and system leaders to develop quality and safety strategic plans and infection prevention plans.
  • Provides direct supervision of the staff and assists in their development and competency.
  • Provides leadership for regional quality/safety/infection prevention committees, including Board quality committees and provides direction for the medical center's QICs.
  • On an on-going basis, identifies problem areas in need of focused attention - plans and oversees implementation of actions to drive improved outcomes.
  • Achieves the best outcomes aligned to CMS and other pay for performance programs, including those that are aligned to commercial carriers.
  • Provides leadership and ensures regulatory compliance, including continuous Joint Commission readiness, CMS (including pay for performance programs, star quality program, etc.) and the Iowa Department of Inspections and Appeals compliance as pertains to quality and patient safety.
  • Provides leadership for continued improvement with regards to outside rating organizations, including: CMS, Leapfrog, US New and World Report, Health-grades, etc.
  • Collaborates with the VP of Patient Care and nursing leaders in meeting/exceeding Magnet standards of excellence and achieving Magnet designation.
  • Develops performance excellence systems that integrate LEAN and other methodologies as appropriate to create a premier data-driven quality improvement programming across the region. In collaboration with clinical leadership, participates in the development, monitoring, reporting, and improvement of quality/patient safety/infection prevention activities related to their respective service lines/departments.
  • Provides appropriate oversight, support, and/or consultative services (project design, selection of data required, development of documentation tools, etc.) to quality improvement teams.
  • Develops and implements a plan to improve the organization's Culture of Safety - including the concept of a Just Culture and TogetherSafe.
  • In coordination with Risk Management, recommends and supports opportunities for improvement on all Root Cause Analyses (RCAs) to ensure completeness, thoroughness, creditableness and timeliness.
  • Analyzes, aggregates, tracks and trends occurrences/sentinel events/RCAs and identifies outcome reports to include corporate and facility specific trends and patterns.
  • Oversees clinical data gathering/analytics. Develops/facilitates accuracy of scorecards/dashboards that enable clear reports for internal and external customers.
  • Collaborates with the senior leadership team in the development and implementation of operating and capital budgets.
  • Promotes an environment of shared leadership and decision-making.
  • Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Trinity Health's Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior.
  • Supports organizational evidence-based practice, innovation and research and facilitates engagement with the MercyOne IRB.
  • Oversees and guides the clinical contracting process, consistent with legal and regulatory requirements.
  • Contributes to the process for evaluating medical staff performance, including the focused and ongoing professional performance review process.
  • Provides administrative oversight and support of the medical staff services department and the Medical Executive Committee.
  • Maintain awareness of and respond to issues in areas including the following:o Ethnic, cultural and diversity changes in the populationo Political and social influenceso Financial and economic issueso The aging of societyo Ethical issues related to healthcare
  • Perform other duties consistent with purpose of job as directed.SKILLS AND ABILITIES REQUIRED:
  • A thorough understanding of the health care environment and all applicable laws and regulations.
  • In depth knowledge of high reliability organizations, performance excellence, change leadership, shared governance, matrix reporting, continuous improvement, risk management and financial and productivity management.
  • The ability to synthesize and interpret large amounts of clinical, quality, and financial data.
  • Proven time management skills with the ability to prioritize and organize work/projects in a fast-paced working environment so that all tasks are completed on time and accurately.
  • Keeps current in area of expertise and assure that standards and practices reflect best practice within area of expertise.
  • Maintains a professional, collaborative work environment so as to foster a positive public image for MercyOne.
  • Possesses a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of MercyOne and Trinity Health.
  • Provides a high level of customer responsiveness and serves as a role model to encourage a commitment to customer service. A strong service orientation is required.
  • Excellent written and verbal communication skills with the ability to relate to people across all levels & diverse backgrounds; ability to handle interactions with discretion, tact & courtesy.
  • Strong relationship builder, consultant and demonstrate the ability to deal successfully with inherent ambiguities and complexities of a multi-site organization.
  • Demonstrates leadership and management abilities. Highly skilled in management technique, primarily in the areas of consensus and team building, colleague engagement, delegation, conflict management, etc.
  • Flexible and demonstrates a great tolerance for change with ability to manage self and others through change.
  • High aptitude for learning quickly, acting maturely and ethically.
  • Ability to think creatively and analytically.
  • Ability to demonstrate initiative.
  • High degree of professionalism.
  • Ability to handle confidential information in a sensitive manner.
  • Demonstrates leadership skills and ability to implement processes and procedures.EDUCATION, LICENSURE, CERTIFICATION, AND EXPERIENCE REQUIRED:
  • Education:o Masters Degree in Nursing. Doctoral education preferred.o Iowa licensure as a Registered Nurse.
  • Experience:A. Requires a minimum of five (5) years progressive leadership experience, preferably at the director level.B. National certification in risk management and/or quality/safety required or must acquire within 2 years of hire. LEAN Six Sigma certification preferred.
  • Special Skills, Competencies, and Aptitudes:A. Member of a professional nursing organization.B. Demonstrated expertise in the use of performance improvement methodology/tools.C. Must be able to use computers for documentation and other relevant activities. Demonstrates specific knowledge related to software programs such as VOICE (or other incident reporting system) and other appropriate software programs. Experience with computer applications such as Microsoft Office Suite (Word, Excel, PowerPoint, Outlook), HealthStream, Intranet, and use of reporting tools. Helpful to have experience with PowerChart or similar tool.Our Commitment to Diversity and InclusionTrinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.Our Commitment to Diversity and InclusionTrinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.EOE including disability/veteran

Keywords: Trinity Health, Dubuque , Eastern Region Director, Quality & Safety, Executive , Dubuque, Iowa

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