Director of Quality Safety and Staff Development - Gilchrist

The Director of Quality, Patient Safety, and Staff Development-Gilchrist, assists in the development and implementation of quality, patient safety, and accreditation standards. This role will also assist with assessing and identifying the training needs of clinical staff, and working in collaboration with the Senior Leadership, develop and deliver education, coaching, and training for clinical staff to ensure safety and compliance standards. This role will also monitor, review, and stay abreast of changes within regulatory rules and change within the appropriate accreditation organization, as well as federal, state and local government regulations that impact end of life care. The Director will provide leadership and work directly with managers, providers and staff to foster clinical effectiveness and quality outcomes and advance a culture of excellence throughout the organization. Knowledge, Skills and Abilities Ability to identify system failures and facilitate changes that will lead to improvement Expert skill in oral and written communication, including demonstrated facilitation skills with diverse groups Performance improvement skills including root cause analysis and model for improvement Skill in managing multiple priorities and demonstrated ability to meet deadlines under all types of circumstances Strong clinical analysis and investigative skills necessary to assess patient safety occurrences, risk events and variances in clinical quality outcomes. Strong leadership and management and group facilitation skills. Ability to influence and negotiate individual and group decision-making. Advanced interpersonal skills to manage, direct, and coordinate the activities of multiple departments to positively communicate and work with professionals at all levels of the organization Ability to manage circumstances where uncertainty is inherent. Mentoring and coaching management-level staff by providing open and honest feedback that results in enhanced performance outcomes. Skilled communicator and expert in facilitating safety events such as RCA, FMEA, and other root cause and effect tools. Mentors and drives engagement with direct reports and department leaders in individual areas of oversight using the organization’s Leadership System. Ability to read, interpret and apply regulatory and accreditation requirements. Solid understanding of CMS, CoPs, and CHAP standards. Technical skills include comfort and familiarity with Microsoft Office programs and ability to assemble and analyze data for meaningful results. Projects and role models a professional image at all times in both action and presence. Principal Duties and Responsibilities Oversees the organization’s quality and patient safety program. Works collaboratively with senior leaders, clinicians and others throughout the organization to guide systems improvement that supports the achievement of assigned strategic initiatives. Provides direction and counsel to identify and resolve variances in clinical quality outcomes, accreditation requirements and processes related to patient safety and risk management Oversees the data collection and reporting of all external clinical quality outcomes. Ensures data submissions are accurate and timely. Provides clinical leadership to direct reports and others in the organization necessary to guide improvement to achieve strategic objectives. Oversees timely follow-up and corrective actions completed within the department related to safety events, accreditation and regulatory surveys and other improvement activities. Oversees the process for root cause analysis for Level 1 and Level 2 events and Level 3 events as appropriate to ensure system failures are identified and corrective actions are implemented. Completes reports as required for the OHCQ or other regulatory body. Oversees peer review program ensuring timely and accurate reviews, identification of trends and responding to the needs for ongoing and focused professional review. Fosters a collaborative learning approach with the medical staff. Oversees departmental data including patient safety events, grievances, peer review, clinical quality outcomes, safety culture data; ensures those responsible maintain data accurately. Facilitates analysis of data and collaborates with key leaders to drive strategic change and improvement. Fosters a culture of safety and reliability . Serves as the internal expert on quality, safety and accreditation and provides coaching and education at all levels in the organization. Provides verbal and written reports to Board of Directors, Senior and Medical Staff Leaders and others in the organization related to outcomes, patient safety, regulatory compliance and other quality initiatives. Reviews, monitors, and stays abreast of requirements of Medicaid, Medicare, CHAP, and any other federal, state or local regulatory body/agency; assists with ensuring Gilchrist leaders are updated on trends in regulations, managed care, and other healthcare authorities that impact employees, patients, or services. Responsible for developing annual budget and oversight of same. Collaborates with leadership to identify improvement opportunities based on learning from patient safety events and regulatory/accreditation surveys and tracers. Facilitates shared organizational learning to help achieve strategic objectives. Responsible for oversight of the CHAP accreditation process, including annual periodic performance reviews, on-site surveys, corrective actions and ongoing organizational readiness. Oversees and works with appropriate leaders to ensure that processes are in place to meet accreditation standards and regulatory requirements. . When standards are not met, facilitates corrective action plans are developed, implemented and fully executed. Oversees the performance of routine tracer activity to assess the organization's compliance to regulatory and accreditation standards. Oversees all survey preparedness activities conducted by Chapter Leaders. Serves as a resource and provides coaching and education as appropriate related to accreditation and regulatory compliance. Provides leadership, guidance and direction to direct reports. Fosters a culture of teamwork, trust and accountability within the department. Supports clinical operations by partnering with senior leadership, providers, and staff to ensure the highest quality of care and outcomes. Staff Development and Education: Annually identifies all staff developmental needs and assures appropriate staff education/training/support. Oversees the development, implementation, and monitoring of our orientation and annual education program. Collaborates in the planning, development, coordination, and presentation of specific training and educational programs as appropriate to the strategic, regulatory quality improvement, and patient safety needs of the organization. Physical Requirements Sitting, walking, standing, driving. Must be able to stand and walk for several hours on a routine basis. Working Conditions Office, clinical care units and or patients’ homes. Education: Bachelor’s degree in business, nursing, or a health-related field; Master’s degree preferred. Patient safety training or certification preferred Experience Five years of progressive experience in healthcare quality, compliance, and patient safety with focus on end-of-life care Experience in leading Joint Commission and/or CHAP accreditation and CMS Surveys in post-acute settings, hospice and end of life preferred. Knowledge and experience with value-based purchasing models, as related to hospice and end of life. Demonstrated experience using performance improvement skills such as Lean or Six Sigma and experience conducting Licensures, Certifications Current registration with the Maryland State Board of Examiners of Nurses as a Registered Nurse, or other advanced clinical license

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