Director Quality/Patient Safety - West Penn Hospital, Hybrid, Pittsburgh, PA

The Director of Quality and Patient Safety is responsible for the successful implementation of the AHN enterprise-wide quality and patient safety goals and objectives for the designated location.  Oversees the quality and patient safety functions while working in tandem with the QSV division (including infection prevention, regulatory preparedness and pay for value) and the corporate departments (Risk Management, Legal, Privacy and Compliance).  Accountable for driving results to achieve top performance for all clinical, pay for value and patient safety outcomes which include, but are not limited to:  Hospital acquired infections, Core Measures, Patient Safety Indicators, CMS/P4V program measures, Culture of Safety.  Responsible for driving and/or supporting Lean Improvement efforts to realize efficiencies and maximize resource utilization.

ESSENTIAL RESPONSIBILITIES 

• Perform management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.  Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority. (20%)
• Lead and/or facilitate internal quality and patient safety initiatives to achieve successful outcomes and minimize harm to patients and staff while promoting a Culture of Safety. (15%)
• Maximize impact of implementing Culture of Safety and pay for performance programs including focused effort on opportunities for improvement within the designated location/institute. (15%)
• Serve as a liaison to the Institute Quality Programs to support best practices, standardize process measures and drive performance outcomes. (10%)
• Partner with the Data Analytics Team to ensure timely reporting and communication of information to promote decision making. (10%)
• Lead a multidisciplinary initiative that focuses on safety reporting, root cause analysis and development of improvement proposals. (10%)
• Provides expertise in the use of tools to assess quality and safety risks and harm events such as:  RCA, FMEA, etc. (5%)
• Reports safety events to PA-PSRS, MedSun, CMS, TJC according to the type of event and within the timeframes legally established. (5%)
• Ensure capture and management of OPPE (ongoing professional practice evaluation) information and reporting. (5%)
• Oversight of regulatory activities including (but not limited to):  PI chapter of the Joint Commission, Hospital specific Performance Improvement and Patient Safety Plan. (5%)
• Other duties as assigned.

QUALIFICATIONS:

Minimum 

• Master's Degree in Clinical; Health Administration
• 3 years of experience in developing, implementing and achieving outcomes in process improvement and patient safety initiatives
• 1 year of Leadership experience
• 1 year of Clinical experience in nursing, pharmacy or other health related field
• Certification - Certified Professional in Patient Safety (CPPS) or Certified Professional in Healthcare Quality (CPHQ) (Obtain within one year of hire)
• Microsoft Office/Computer skills

Preferred 

•  None

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. 
 
Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. 

 
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.  
 
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.