Senior Director

POSITION SUMMARY:

• Oversees the systems regulatory processes, and will recommend, implement or direct process and infrastructure improvements that support the reduction of medical/health care errors and other factors that contribute to unintended adverse patient outcomes and regulatory non-compliance for Steward Health Care System.
• Provides leadership for patient safety assessments, and will ensure all hospitals have an ongoing regulatory readiness program to meet all applicable state and federal regulations such as Department of Public Health Hospital licensing regulations, Department of Mental Health licensing regulations, as well as ensure compliance with DNV, The Joint Commission regulatory requirements as well as Medicare Conditions of Participation.
• Consults with management and staff, communicating evidence-based strategies to ensure best practice within the organization and works with other leaders to establish a culture of safety throughout the system.

KEY RESPONSIBILITIES:

• Facilitates formal mechanisms of communication and networking among clinical leaders across SHC including forums for information sharing, knowledge transfer, best practices, and innovative problem solving specific to the system Quality and Safety Plan. Includes oversight of hospital regulatory readiness, and regulatory responsiveness.
• Collaborates with each hospital’s Director of Quality to evaluate current systems of regulatory compliance and sustainability and make recommendation for standardization and efficiencies, for the system. Specifically, supports the system readiness for The Joint Commission, DNV-, CMS, DMH, DPH/DOH, and other licensing organizations in regards to compliance, survey readiness and self-assessments.
• Oversees the process, review, and refinement of the of system level quality and patient safety initiatives to ensure full implementation of the National Patient Safety Goals throughout the system on an annual basis.
• Designs and provides leadership training for clinical leaders and task forces regarding the use of clinical measures while promoting accountability for achievement of targets for publicly reported measures, including, but not limited to, Joint Commission CORE, CMS, and Leapfrog.
• Recommends and facilitates sustainability efforts system wide to improve quality and patient safety, based on identified risks and system data.
• Support analytic, operational, and strategic leadership in helping to position SHC as a quality and patient safety leader within the health care industry.
• Serves as an expert resource within SHC in identifying and creating a body of knowledge and a data repository related to patient safety.
• Designs measures to evaluate the impact of interventions on publicly reported measures. Works with the analytics team to prepare reports which compare past, current and future conditions. Identifies trends, and highlights opportunities to improve performance.
• Contributes to the development of strategic plans for improving quality. Works with all hospitals in the health care system to assure alignment of strategies for publicly reported measures, including best practice, data collection, vendor relations, reporting tools, and linkages with the electronic medical record.
• In collaboration with Senior Leaders, implements a sustainability program that includes Tracer rounds with defined tools and processes that include feedback from the patient and/ or family.
• Develops standardized tools and provides education as needed to enhance the continuous readiness and sustainability programs
• Attends and facilitates Tracer/Regulatory rounds with senior leadership, communicates finding and follows up as applicable.
• Demonstrates an indepth knowledge and interpretation of regulatory and accreditation standards
• Remains current with regulatory and accreditation changes
• Recommends and facilitates ongoing regulatory readiness program throughout the Steward Health Care System.
• In collaboration with Risk Management personnel, investigates patient safety failures and issues within the system, participates in Root Cause Analysis of internal error reports and critical event reviews.
• Designs and implements educational presentations that facilitate the understanding and implementation of quality, patient safety and regulatory standards throughout the system.
• Serves as a resource for departments on issues of quality, patient safety and regulatory compliance.
• . Make recommendations on employee hires, transfers, promotions, salary changes, discipline, terminations, and similar actions. Resolves grievances and other personnel problems within position responsibilities.
• Assures the information on the Quality and Safety Website is current and in compliance with regulatory and accreditation standards.
• Assists with the onboarding on Quality Director’s at the local level.
• Oversees and manages Regulatory Surveys occurring during the Quality Director’s orientation period
• Provides effective direction, guidance, and leadership over the staff for effective teamwork and motivation and fosters the effective integration of efforts with system-wide initiatives.
• Participates in performance improvement initiatives and demonstrates the use of quality improvement in daily operations.
• Develops and maintains policies and procedures necessary to meet regulatory requirements.
• Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment.

1. Commits to recognize and respect cultural diversity for all customers (internal and external).

2. Communicates effectively with internal and external customers with respect of differences in cultures, values, beliefs and ages, utilizing interpreters when needed.

• Performs other duties as assigned

REQUIRED KNOWLEDGE & SKILLS:

• Highly motivational communication skills accompanied by the ability to analyze and present data to influence behavior, stimulate innovation, promote best practices, and drive organizational change.
• Excellent presentation style, including the ability to present data to clinicians and staff at all levels of the organization.
• A highly skilled change agent with demonstrable sensitivity to the interpersonal, group dynamic, organizational, political, and perceptual issues associated with change.
• Results orientation accompanied by the skill set required to conceptualize, implement, and operationalize a user-friendly clinical excellence and patient safety program.
• Demonstrated ability to create and sustain momentum through relationship building, and collaborative management.
• Will require travel to local sites and may require travel to distant sites as needed.
• Expertise in project management at system and local level

EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:

1. Education: Masters or PhD in a health care field, or RN with Masters Degree or employment with a CMS deemed Accreditation Organization as a surveyor.
2. Experience (Type & Length): 5-10 years experience in a senior clinical leader position with a strong foundation in quality and patient safety