Director of Quality & Patient Safety
Company: UT Health Tyler
Location: Tyler
Posted on: October 17, 2024
Job Description:
Overview
In a joint venture partnership with UT Health System,Ardent
operates UT Health East Texas in Tyler, Texas. UT Health East Texas
is comprised of UT Health Tyler (the area's only Level I trauma
center), UT Health North Campus, UT Health Athens, UT Health
Carthage, UT Health Henderson, UT Health Jacksonville, UT Health
Pittsburg, UT Health Quitman, UT Health Air1/EMS, UT Health East
Texas Rehabilitation Hospital, UT Health Long Term Acute Care, UT
Health Hope Cancer Center and UT Health East Texas Physicians. With
974 licensed beds, UT Health East Texas is advancing healthcare,
together. -POSITION SUMMARY - -The position of Quality and Patient
Safety Director at UTHET is accountable for assisting the
organization to improve quality, safety, and reduce operational
risk exposure through performance improvement processes and meeting
regulatory and accreditation requirements. They will assist in the
implementation of UTHET's Quality/Clinical effectiveness function.
This position supports a culture of high reliability and the
measurement of care quality identifying opportunities and executing
on strategies for performance improvement in the following areas of
the organization: -
- Outcomes - highly reliable processes, delivering exceptional
outcomes and/or optimal health -
- Safety - Deliver the safest care to patients driven through
leadership and a culture of high reliability -
- Accreditation-Ensures all regulatory requirements are managed
and highly functional -
- Experience of Care - relationship-centered care grounded in
empathy, dignity, respect and collaboration -
Responsibilities
- Support a proactive, comprehensive strategic Quality agenda
that inspires caregiver engagement, inter-professional
collaboration, the identification and use of evidence-based
practice and management among all entities in the system while
differentiating UTHET as a high reliability organization
nationally. - -
- Provides accurate and meaningful data to teams, committees and
physician groups by understanding data dictionaries and using
appropriately, using self-coded data sheets, assisting in
determining appropriate data to collect by asking right questions
and identifying correct populations, and using working knowledge of
existing databases to obtain data already being collected. -
- Appropriate knowledge and application of basic statistical
tools, such as, standard deviation, frequency distributions,
histograms, and Pareto charts. -
- Actively participate in divisional meetings, processes, and
activities to ensure Quality functions are disseminated
consistently throughout the division. - -
- Chair and lead the local Performance Improvement Committee. - -
-
- Acts as a liaison between the Performance Improvement Committee
and the Governing Board, to ensure all CMS CoPs are met. - -
- Applies quality improvement methodologies as a quality
representative/facilitator for PI Teams and as a consultant to
provide basic CQI or statistical tools. -
- Evaluates and makes recommendations for system improvements
using quality data, event and regulatory compliance reports. -
- Provides project management to assigned teams by providing
leadership to focus areas and by utilizing facilitation and
assessment skills to develop evidence-based initiatives.
-Regulatory Compliance: -
- Drives all regulatory functions on the local level. -
- Applies a current working knowledge of regulatory compliance
standards as appropriate to assignment or specialty. -
- Participates in all divisional regulatory functions and
standards. - -
- Leads the participation and management of the Internal Quality
Survey process, including timely and appropriate response to action
plans. - -
- Lead and drive the sustainability efforts for all IQS and TJC
action plans to ensure compliance is maintained and practice
changes are hardwired. - - -
- Provides advanced consultation and support by collaborating
with peers throughout the corporation to develop methods and plans
to meet standards, participating in the writing or development of
new policies, procedures and guidelines, researching literature and
outside sources to identify new methods, technologies, or
approaches for compliance, ensuring compliance to regulatory
support and assessing compliance to standards to ensure a safe and
consistent care environment to multiple areas and settings.
-Patient Safety: -
- Leads Mission Zero: Our Culture of Safety on the local level,
based on division standards and expectations. - -
- Leads and/or functions as the Risk Manager on the local level,
based on division standards and expectations. - -
- Applies a current working knowledge of national, local, and
system patient safety standards and trends as appropriate to
assignment or specialty. -
- Leads PSEA and RCA efforts and reports to the Ardent PSO, per
requirements. - -
- Participates in the division SENT process for reporting safety
events. - -
- Participates in the division safety event classification
process. - -
- Provides collaboration and consultative support to Risk
Management, Compliance, Medical Staff, Nursing, and others by
compiling reports with recommendations from appropriate sources,
participating in maintenance of applicable Safety Plans, networking
across departments and facilities to achieve objectives and goals,
participate or facilitate patient safety improvement teams, and
engages and interacts with staff at all levels to encourage
ownership of initiatives. -Practice Standardization and Policies: -
- Advocate and support standardization by educating focus areas
to centrally developed policies, procedures, processes, and forms
and assisting/participating in corporate teams with the development
of policies, procedures, processes, and forms. -
- Participate in development, implementation, revision, and
review of policy, procedures, protocol, guidelines, and forms, when
appropriate for focus areas. -Education: -
- Provides education to focus areas regarding Quality Monitoring
and Improvement, Regulatory Compliance, Patient Safety, Risk
Management, Medical Staff Services and Practice Standardization and
Policies. -Informatics, Data and Analytics -
- Support quality measurements for internal use. -
- Support and distribute standardized reports that are developed
centrally to ensure consistency in data management and reporting
across the division. - -
- Support the deployment and optimization of the electronic
health record to maximize safety, quality outcomes, clinical
effectiveness and efficiency. -
- Advance, with others, the use of predictive analytics and deep
learning computing to improve the health, experience and quality of
care of those we serve.--- - -SUPERVISION: - -Depending on the
facility, the director may be responsible for 3-5 direct reports. -
-
Qualifications
Education and Experience: -
- Required: Bachelor's degree in Business, Healthcare
Administration, Public Health or other business related field.
Education must be obtained through an accredited institution and
will be verified. - -
- Experience leading successful Quality Improvement projects.
-
- Experience with change management with the ability to provide
leadership in the adaptation and implementation of new processes
and /or technology that enhance Quality. -
- Effective verbal, written and interpersonal communication
skills. -
- Experience overseeing patient safety programs. -
- Experience leading teams. -
- Trained in improvement science (i.e., Six Sigma, Lean, UT
System CSE or DMAIC) -
- Experience working in a complex health system (hospitals,
ambulatory clinics, post-acute care, etc.) - -
- Experience with external entities that drive and support
Quality approaches and standards, including government agencies,
academic institutions, universities and related organizations of
higher education, and other public institutions is preferred
- One of the following certifications is preferred-CPHQ, CPXP,
CPSP, CPHRM -
Keywords: UT Health Tyler, Rowlett , Director of Quality & Patient Safety, Executive , Tyler, Texas
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