Dir Clinical Quality & Patient Safety

POSITION SUMMARY

The Senior Clinical, Quality and Patient Safety Director (Executive Director), Department of Surgery has direct responsibility for overseeing, creating, implementing and evaluating all quality and patient safety programs for all specialties in the Department of Surgery. The director independently leads a team to provide comprehensive direction, oversight and leadership to improve outcomes, diminish cost and provide value through standardization of best practices in patient centered care across all service lines and hospital wide based on BMC strategic plans. This position requires extensive cross-functional and system wide relationships beyond the Department of Quality and Patient Safety to be successful in a highly multidisciplinary and complex role. Oversees all aspects of quality program including quality measurement, external reporting, root cause analysis, failure mode analysis and system design. Drives the organization to improve value has extensive knowledge of all aspects of hospital clinical operations as it relates to patient safety, quality, and regulatory accreditation. The Director coaches, mentors and provides research opportunities to improve patient outcomes, clinical efficiency, value and patient satisfaction. Highly involved in using innovation to continuously move the Department of Surgery forward in an academic setting.

Position: Dir Clinical Quality & Patient Safety       

Department: Quality Improvement

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

• Works independently to establish and provide comprehensive direction and oversight by leading a team to provide sophisticated analysis, advice and consultation to surgical divisions as well as hospital wide based on BMC and surgery strategic plan.
• Accountable for ensuring issues of highest criticality and complexity are solved in support of clinical organizational goals
• Responsible to identify, design and lead change initiatives that compel higher performance safer systems and clinical excellence.
• Well versed in regulatory standards, requirements, guidelines for Joint Commission, CMS and DPH.
• Establishes oversight and monitoring to maintain compliance with regulatory accreditation in Kidney Transplant, TACS and other surgical divisions
• Fosters professionalism, actively engages department leaders and team members to create a positive supportive culture for staff, patient and families creating a culture of safety
• Provides visionary leadership to ensure BMC is striving for performance excellence that is important in the future of innovative healthcare
• Ensures patient safety events are tracked, categorized and analyzed for improvement opportunities and oversees investigative process for evaluating adverse events and near misses
• Responsible for management of high risk, problem prone areas of opportunity for improvement and ensures problems are prioritized and leading teams working to resolve them
• Ability to demonstrate sound critical thinking and decision making demonstrating cooperative communication working with others to problem solve challenging issues
• Collaboration and partnership with Department Chairs/Chiefs, Nursing Leadership and Administration to plan, develop, and enact interdisciplinary efforts regarding current and future surgical/hospital wide improvement projects
• Thoroughly analyze trends and areas of opportunity based on surgery databases, Vizient, ARHQ,CMS and other emerging quality measurements, directing the development and implementation of new clinical programs improving outcomes with increased efficiency and value
• Involvement in high-priority projects as they occur
• Identification of clinical problems leading teams to monitor and improve clinical effectiveness utilizing rapid cycle approach and systems-based strategies and interventions, coordinating efforts with leaders/staff throughout the organization
• Build strong collaborative relationships at all levels with multidisciplinary/interdepartmental teams to accomplish goals and promote favorable change
• Demonstrate excellent leadership, communication skills, creativity and enthusiasm for developing innovative quality improvement programs
• Oversee standardized practices and systems (e.g. ICOUGH, Caprini VTE etc.) including support and collaboration with other departments
• Oversee teams that coordinate and standardize multidisciplinary care including Surgery, QI, Anesthesia, ED, Nursing and Medicine
• Restructure the Pre Procedure Clinic to a model of risk assessment, risk stratification and patient education looking at improving the model and fast-tracking patients to increase the overall volume and enhance patient safety
• Enhance perioperative communication among surgeons and their teams improving outcomes by focusing on patient –centered care with standardization of pre-op and post-operative discharge instructions
• Oversee the development of a multidisciplinary team to focus on standardization of discharge instructions throughout the Division of surgery, with online and innovating texting modalities.
• Support, monitor and reinforce clinical practices for surgical initiatives such as ICOUGH, Caprini VTE prophylaxis system, prevention of GT/PEG dislodgements and other programs, working closely with QI analytic team to create dashboards to monitor compliance.
• Expand ICOUGH nationally and internationally to other medical centers via consultative services
• Participate in grant writing and research proposals as a BU QI Hub faculty member
• Facilitate Department of surgery growth in clinical volume, based on standardized practices and excellent outcomes
• Lead and oversee both internally and externally data submissions are accurate and submitted to satisfy deadlines.
• Provide and present pertinent quality and patient safety data and related information in a timely manner
• Serve as an expert clinical resource to multidisciplinary teams assisting with high-level data analysis to identify opportunities for improvement
• Lead, coach and mentor my team to oversee and evaluate comprehensive QI and patient safety programs, strive to improve clinical outcomes utilizing process improvement methodology in projects and strategic initiatives to provide team growth opportunities.
• Educate clinical staff, students, residents, faculty regarding quality and patient safety opportunities to improve selected aspects of clinical care utilizing clinical data relative to national standards as well as specific actions necessary to accomplish institutional goals
• Actively network internally, externally, nationally and internationally to identify opportunities to promote the Department of Surgery. Participate in pertinent professional education to maintain current knowledge of best practices for the improvement of care for surgical patients and hospital wide.
• Utilize the Department and Boston Medical Center’s culture as the basis for decision-making and to support the shared mission and goals

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).

JOB REQUIREMENTS

EDUCATION:

• Baccalaureate in nursing; Master's degree in health related field required.

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:

• Licensed as a registered nurse in the Commonwealth of Massachusetts.

EXPERIENCE:

• At least 5 years of active clinical practice experience;
• Leadership experience for at least 5 years
• Project management and program development experience essential
• Experience with NSQIP, UHC, and other QI data sources is essential
• 2 or more years of experience in clinical quality improvement strongly preferred;

KNOWLEDGE, SKILLS & ABILITIES (KSA):

• Strong computer skills including Microsoft Office platform—Word, Access, Excel, E-mail. Web/Internet.
• Management and leadership skills
• Exceptional organization and communication skills
• Administrative skills
• Excellent presentation skills
• Ability to collaborate with internal and external staff and resources
• Experience with grant writing and submission
• Ability to learn and effectively use computer software, such as electronic health records and data entry tools.
• Demonstrated skill and effectiveness in clinical quality improvement strongly preferred.
• Strong interpersonal skills; ability to establish supportive, collegial relationships;
• Excellent English communication skills (oral and written).
• Strong writing skills.

Equal Opportunity Employer/Disabled/Veterans

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