Wellstar Health System
Executive Director, Quality & Safety
Wellstar Health System, Roswell, Georgia, United States, 30076
Job Summary
The Executive Director of Quality and Safety is responsible for developing a vision and executable plan to attain world‑class quality and safety processes and procedures across the hospital and all hospital outpatient departments (HOD) and associated Health Parks. Accountable for ensuring successful development and deployment of the WellStar Quality and Safety strategy in a manner that supports achievement of WellStar Quality goals. With patient safety and clinical quality expertise, the incumbent partners with leadership, staff and system partners to identify opportunities for short and long‑term impact on quality and safety outcomes in alignment with WellStar’s strategic plan.
Core Responsibilities And Essential Functions
Provide centralized direction, governance and leadership for major projects and programs related to quality performance and patient safety.
Develop and implement the long‑term and short‑term strategy for safety and quality.
Ensure governance‑level quality reports and communications support the Board of Trustees and delegated board committees to meet fiduciary responsibilities.
Meet all regulatory & accreditation requirements with respect to periodic quality and safety related reports.
Serve as liaison to all local‑level business units and entities for oversight and advising on quality improvement projects and their alignment with system goals.
Manage quality improvement and infection control for the hospital and associated Health Parks.
Chair and participate in quality committees coordinated/facilitated by the department, including Quality Review, Infection Control, Value, Medication Safety, and Peer Review.
Integrate other appropriate improvement and high‑reliability strategies and tools; provide advisory coaching and educational training on process improvement projects, methodology, tools, and standards.
Mitigate medical/legal liability through development of a program linking risk management activities with continuous performance improvement.
Contribute to management of accreditation, regulation, and licensing activities, including communicating programs/processes to providers and medical staff, preparing surveys and inspections, and completing assessments, response plans and measures of success.
Oversee the Safety Event Management Program: investigate quality of care incidents and near misses, collaborate with system and facility leadership to foster reporting of all safety events, and oversee and facilitate reliable safety event classifications and documentation in the electronic event reporting system.
Lead cause‑analysis training and root‑cause analyses processes for WellStar reportable events, fostering identification of reliable root causes, action plans, measures of success, and shared learning across the system.
Contribute to the Infection Control Management Program: support infection prevention and control practices, conduct surveillance activities, investigate infection control problems and outbreaks, and identify responses to improve patient care systems and mitigate risk.
Coordinate Quality and Patient Safety training, including Simulation/Conduct, periodic Environment of Care survey, annual mock accreditation survey, and Failure Mode and Effects Analysis for newly internalized services.
Evaluate staff performance and development, develop, monitor, and control department budgets, recommend need for staff, space, and resources, and perform other duties as assigned.
Comply with all WellStar Health System policies, standards of work, and code of conduct.
Human Resources Management Processes
Responsible for evaluating staff performance and development.
Develops, monitors, and controls department budgets.
Makes recommendations regarding the need for staff, space, and other resources.
Performs other duties as assigned.
Complies with all WellStar Health System policies, standards of work, and code of conduct.
Required Minimum Education
Masters in Public Health or Health Administration or Business Administration/Management or Nursing or another relevant graduate degree.
Required Minimum License(s) And Certification(s)
CPHQ – Certified Professional in Healthcare Quality.
Additional License(s) And Certification(s)
RN Reg Nurse (Single State) – preferred.
RN‑COMPACT RN Multi‑State Compact – preferred.
Required Minimum Experience
Minimum 5 years of progressive experience in healthcare quality services or support.
Minimum 5 years of experience managing a team directly, or equivalent project or functional leadership within quality services.
Previous experience with proven leadership in regulatory and accreditation survey readiness, quality improvement and patient safety in a large acute care system or facility.
Strong experience with patient safety event management, including conducting root cause analysis and facilitating creation of effective, timely action plans.
Experience leading improvement work using a scientific methodology.
Lean management system and Lean Production System methodology preferred.
Experience coordinating with and reporting data to a Patient Safety Organization (PSO) preferred.
Experience managing and/or monitoring infection prevention functions preferred.
Required Minimum Skills
Strong interpersonal skills with the ability to communicate and work with all levels of healthcare providers, including physicians.
Ability to perform duties and responsibilities promptly and consistently with little direct supervision.
Ability to execute a plan and use project management methodology.
Ability to plan and direct activities of others and provide feedback regarding outcomes or performance.
Ability to work collaboratively with other departments within and outside the hospital.
Ability to judge the appropriate action in response to changes, circumstances, or problems.
Experience in data collection, analysis and project management.
Strong computer skills.
Excellent communication, presentation and organization skills.
Working knowledge of data collection methodologies, interpretation/analysis and decision support databases.
Exposure to workflow in event management systems with the ability to interpret and utilize trended event data to improve safety.
Seniority Level Executive
Employment Type Full‑time
Job Function Quality Assurance
Industries Hospitals and Health Care
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Core Responsibilities And Essential Functions
Provide centralized direction, governance and leadership for major projects and programs related to quality performance and patient safety.
Develop and implement the long‑term and short‑term strategy for safety and quality.
Ensure governance‑level quality reports and communications support the Board of Trustees and delegated board committees to meet fiduciary responsibilities.
Meet all regulatory & accreditation requirements with respect to periodic quality and safety related reports.
Serve as liaison to all local‑level business units and entities for oversight and advising on quality improvement projects and their alignment with system goals.
Manage quality improvement and infection control for the hospital and associated Health Parks.
Chair and participate in quality committees coordinated/facilitated by the department, including Quality Review, Infection Control, Value, Medication Safety, and Peer Review.
Integrate other appropriate improvement and high‑reliability strategies and tools; provide advisory coaching and educational training on process improvement projects, methodology, tools, and standards.
Mitigate medical/legal liability through development of a program linking risk management activities with continuous performance improvement.
Contribute to management of accreditation, regulation, and licensing activities, including communicating programs/processes to providers and medical staff, preparing surveys and inspections, and completing assessments, response plans and measures of success.
Oversee the Safety Event Management Program: investigate quality of care incidents and near misses, collaborate with system and facility leadership to foster reporting of all safety events, and oversee and facilitate reliable safety event classifications and documentation in the electronic event reporting system.
Lead cause‑analysis training and root‑cause analyses processes for WellStar reportable events, fostering identification of reliable root causes, action plans, measures of success, and shared learning across the system.
Contribute to the Infection Control Management Program: support infection prevention and control practices, conduct surveillance activities, investigate infection control problems and outbreaks, and identify responses to improve patient care systems and mitigate risk.
Coordinate Quality and Patient Safety training, including Simulation/Conduct, periodic Environment of Care survey, annual mock accreditation survey, and Failure Mode and Effects Analysis for newly internalized services.
Evaluate staff performance and development, develop, monitor, and control department budgets, recommend need for staff, space, and resources, and perform other duties as assigned.
Comply with all WellStar Health System policies, standards of work, and code of conduct.
Human Resources Management Processes
Responsible for evaluating staff performance and development.
Develops, monitors, and controls department budgets.
Makes recommendations regarding the need for staff, space, and other resources.
Performs other duties as assigned.
Complies with all WellStar Health System policies, standards of work, and code of conduct.
Required Minimum Education
Masters in Public Health or Health Administration or Business Administration/Management or Nursing or another relevant graduate degree.
Required Minimum License(s) And Certification(s)
CPHQ – Certified Professional in Healthcare Quality.
Additional License(s) And Certification(s)
RN Reg Nurse (Single State) – preferred.
RN‑COMPACT RN Multi‑State Compact – preferred.
Required Minimum Experience
Minimum 5 years of progressive experience in healthcare quality services or support.
Minimum 5 years of experience managing a team directly, or equivalent project or functional leadership within quality services.
Previous experience with proven leadership in regulatory and accreditation survey readiness, quality improvement and patient safety in a large acute care system or facility.
Strong experience with patient safety event management, including conducting root cause analysis and facilitating creation of effective, timely action plans.
Experience leading improvement work using a scientific methodology.
Lean management system and Lean Production System methodology preferred.
Experience coordinating with and reporting data to a Patient Safety Organization (PSO) preferred.
Experience managing and/or monitoring infection prevention functions preferred.
Required Minimum Skills
Strong interpersonal skills with the ability to communicate and work with all levels of healthcare providers, including physicians.
Ability to perform duties and responsibilities promptly and consistently with little direct supervision.
Ability to execute a plan and use project management methodology.
Ability to plan and direct activities of others and provide feedback regarding outcomes or performance.
Ability to work collaboratively with other departments within and outside the hospital.
Ability to judge the appropriate action in response to changes, circumstances, or problems.
Experience in data collection, analysis and project management.
Strong computer skills.
Excellent communication, presentation and organization skills.
Working knowledge of data collection methodologies, interpretation/analysis and decision support databases.
Exposure to workflow in event management systems with the ability to interpret and utilize trended event data to improve safety.
Seniority Level Executive
Employment Type Full‑time
Job Function Quality Assurance
Industries Hospitals and Health Care
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