Sr Director of QualityPatient Safety

Description

Nashville General Hospital is hiring a Full Time Sr Director of Quality/Patient Safety for Quality Assurance in Nashville Tennessee.

Shift: Day Shift

Primary Duties and Responsibilities

Patient Safety & High-Reliability Operations
Oversee hospital-wide patient safety programs including:
Event reporting systems
Root Cause Analyses (RCA)
Failure Mode and Effects Analysis (FMEA)
Serious safety event management
Promote Just Culture principles and psychological safety for staff.
Lead efforts to reduce hospital-acquired conditions (HACs) preventable readmissions and adverse
events.
Ensure timely follow-up corrective action planning and sustainability of safety improvements
Quality & Regulatory Readiness:
Implement maintain and evaluate a comprehensive Quality and Patient Safety program that oversees care delivery
performance and outcomes.
Serve as the primary point of contact for The Joint Commission CMS CDC and Leapfrog; coordinate all
accreditation standards surveys and reporting in collaboration with leaders.
Lead clinical risk management investigations incident report analysis and serve as a lead investigator for Root
Cause Analysis (RCA) and Failure Mode and Effects Analysis (FMEA).
Oversee the integration of infection prevention and contamination control principles across all hospital units.

Clinical Excellence & Professional Development:
Direct an integrated program for clinical excellence incorporating Lean Six Sigma Change Management and
Project Management methodologies into staff development.
Oversee the peer review program and Ongoing Professional Practice Evaluation (OPPE) support in conjunction with
physician leadership to ensure medical staff competency and high-quality care.
QI support with GME programs leading and responsible for Patient Resident Safety
Transfer and implement High Reliability Organization (HRO) principles behaviors and tools across the
organization to foster a culture of safety and excellence.
Link clinical outcomes and patient satisfaction data to targeted professional development initiatives to address
identified performance gaps.

Data Analysis and Reporting
Oversee the collection validation analysis and interpretation of quality and patient safety data.
Identify trends disparities and opportunities for improvement.
Present quality and safety performance reports to executive leadership medical staff committees and the Board of Trustees

Experience
This senior executive position requires a minimum of 10 years of progressive healthcare leadership experience. This must include at least 3 to 5 years in a senior leadership role (e.g. Senior Director or Director) within an acute care hospital with ambulatory settings with a preference for experience in an Essential Hospital or a similar complex healthcare ideal candidate will have a proven track record in the design development and implementation of Quality Incident Management and Patient Safety programs. They must demonstrate success in improving clinical quality and patient experience outcomes by utilizing Lean Six Sigma and High Reliability Organization (HRO) principles. Experience in a teaching hospital or academic medical center particularly in collaborating with Medical Staff Services and physician leadership for peer review and OPPE support is highly preferred

Required Skills & Qualifications:

• Bachelor level of Nursing;
• Active RN Licensure required.
• Masters degree in Nursing (MSN) Healthcare Administration (MHA) Business Administration (MBA) Quality and Safety (MHA) or a related field
• Two of the following certifications (or equivalent) CPHQ CPSO CQMS CLSSB at the time hire or obtained within 12 months of hired date (Candidates with a nursing or other clinical license will be given special consideration)
• A minimum of (3) years of experience in the role of Director Senior Director or comparable at an acute care hospital preferably at an Essential Hospital or hospital operating in a similar capacity.
• A minimum of (3) years of direct experience in the design development and implementation of Quality/Incident Management/Lean/Patient Safety/Patient Experience/HRO.
• Knowledgeable of Joint Commission CMS CDC and Leapfrog standards and demonstrated proficiency navigating the assessment and survey processes to achieve desirable and sustainable outcomes.
• Strong practitioner of LSS Quality Management System assessment and analysis risk and error reduction human factors etc. tools and techniques.
• Must be able to link and make relevant care/services outcomes to patient satisfaction financial and other NGH goals.
• Doctorate in Nursing Practice (DNP) Doctor of Healthcare Administration (DHA) or related field (Ph.D.).

Title of Certification / License: Active TN nursing license. BLS certified. ACLS required within 30 days of hire.

About Nashville General Hospital

Nashville General Hospital (NGH) is Nashvilles original community- based hospital. Joint Commission accredited NGH readily accommodates a wide range of needs from emergency services and acute care to ancillary and ambulatory services. NGH continues to maintain its strong commitment to the healthcare needs of Nashville and Davidson County underserved while also providing care to all segments of the community.

Our benefits include:

• Medical Dental and Vision Insurance within first 31 days of employment
• Programs to reduce share of deductible and total out-of-pocket expenses
• Metro Health Incentive Program - Access to high quality healthcare without incurring out-of-pocket expenses (see NGH providers without co-pays)
• Short and Long-Term Disability - up to 60% of eligible weekly pay
• Life Insurance - Metro provides you with basic life and AD&D coverage equal to $50000 ($32500 if you are age 65 or older) at no cost to you.
• Retirement Plan - eligible up to IRS max limits and includes company contribution
• Shift and Weekend Differential Pay Offered on Nights and Weekends
• Tuition Reimbursement for employee and dependents
• 12 paid holidays - any holiday worked is another holiday banked
• Flexible Spending Accounts
• Onsite Gym
• Free Parking for all employees

Join our team at Nashville General Hospital. Apply today!

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