Exec Dir, Safety And Quality

New Haven, CT
Aug 14, 2019

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Job Description

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values-integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.

EEO/AA/Disability/Veteran

SUMMARY
Directly reports to the
Medical Co-Directors of Quality Improvement Support Services (QISS) and works collaboratively
with members of the Senior Operations Group, management teams and Medical Staff
Leadership. He/she has responsibility for providing direction, planning,
implementation, evaluation and consultation to ensure that Performance
Management, Patient Safety and Infection Control/Epidemiology requirements are
met (e.g., CMS, DPH, TJC, CDC) across both campuses of Yale New Haven Hospital
and all outpatient sites. This involves working to improve key processes,
policies and procedures in a collaborative manner with stakeholders across the
organization aligned with the mission, vision, values and strategic goals of
the organization. He/she serves as YNHH's primary contact for communication
with CMS-governed data management systems (i.e., QualityNet, CDAC) as well as Yale-New
Haven Health System's Performance Management measurement systems (i.e., VIPER,
Premier). He/she is primarily responsible for coordination of all QISS reports
and projects that support process improvement for performance management,
patient safety and infection control which include, but are not limited to NHSN
reporting of hospital acquired infections, CMS CORE and Value Based Purchasing
Measures, Medical Staff monitoring committees and Healthcare Performance
Improvement (HPI) patient safety initiatives. This work requires extensive knowledge,
skills and expertise in change and performance management. This position will
lead a diverse group of staff skilled in assisting the organization in
achieving success in mission critical initiatives through project management,
process improvement, consultation, facilitation and collaboration. This will
require departmental management of staff (recruiting, hiring, managing,
evaluating and disciplining), employee engagement activities (surveys, staff
meetings, education planning, succession planning, etc.), and management of
departmental budget.

RESPONSIBILITIES
1. In collaboration
with the Senior Vice President, Performance Management, manages Performance
Improvement (PI) Plan
implementation for YNHH.
1 .1 Develops yearly PI
plan with input from stakeholders and effectuates such plan over the course of
the fiscal year
1 .2 Manages Patient Safety
and Quality Council (PSQC) on behalf of the Senior Vice President,
Performance Management.
1 .3 Serves as a senior
management resource by providing expert knowledge of quality improvement theory/methodology,
statistical analysis and problem solving relative to unit and hospital workflow
and processes.

1 .4 Identifies
priority PI projects and deploys resources to match skill sets with project
needs.
1 .5 Accountable for
identifying, recommending, implementing and evaluating best practices using
data driven methodical approaches to problem solving and sustaining
achievements in areas of assignment.
1 .6 Routinely consult
with Senior Management, Legal and Risk Management Services, Medical Staff and other
patient safety and quality staff to execute the PI program throughout the
organization .
1 .7 Demonstrates
skillful collaboration with the performance management and patient safety staff
across the facility to accomplish the PI plan goals.
1 .8 Demonstrates
high-level knowledge and skills in key behaviors that reflect expertise in
communication, customer service orientation, professionalism, problem solving,
resource management, results orientation, teamwork and cooperation, business
and organizational expertise, leadership and managing performance.
2. In collaboration
with Co-Directors, directs and manages QISS operations
2 .1 Evaluates and
modifies department goals and action plans annually and as necessary.
2 .2 Develops and
monitors timetables, budgets and resources to complete QISS goals and projects.
2 .3 Manages all
aspects of human resources for the department, including recruitment,
management and evaluation of staff.
2 .4 Meets frequently
with employees and plans mutually agreed upon individual performance goals. Monitors
progress and/or barriers, plans remedial education and/or training, modifies
performance expectations and completes all reviews as required.
2 .5 Represents QISS at
hospital management meetings as a part of the QISS leadership team.
2 .6 Schedules, plans,
facilitates and conducts staff meetings.
2 .7 Manages
departmental budget and oversees non-invested funds.
2 .8 Maintains an
exceptional work environment through effective leadership, supervision, role
modeling and communication.

2 .9 Develops, plans,
implements and evaluates QISS projects and facilitates the dissemination of
results through presentations, automated electronic reports and/or
publications.
3. Direct all aspects
of required data reporting for performance management requirements to all regulatory
and accrediting bodies.
3 .1 Facilitates and
serves on various committees to assure regulatory and accrediting body
readiness in terms of data collection, display, benchmarking and action
planning.
3 .2 Serves as the main
liaison for Yale New Haven Health System abstraction and performance management
data functions. This includes multidisciplinary review of missed opportunities,
federal submission requirements and reporting of ROI on any and all programs
associated with fiscal penalty/incentives.
3 .3 Assures all CMS,
CDC, DPH and TJC required datasets are collected, aggregated, displayed and analyzed
with appropriate action planning as required.
3 .4 Keeps abreast of
current PI chapter requirements for The Joint Commission and maintains compliance
with this entire chapter.
3 .5 Provide
leadership, guidance and direction to clinical departments in terms of project
and data management for performance improvement projects.
3 .6 Creates, directs
and supports development of strategic educational and training programs
relating to performance improvement.
4. Serves as the main
contact for assigning, directing and managing resources for quality improvement,
patient safety and infection control projects.
5. Manages all aspects
of the patient safety program including the Great Catch Award, HPI initiative
(SSE calculation and review, morning safety report and rounding to influence
program) and incident reporting system.
6. Performs other
assignments as required and/or directed by Senior Vice President, Performance
Management, Chief of
Staff and/or Chief Executive Officer.
7. Enhances knowledge
in the field of infection prevention, clinical quality improvement, healthcare quality
monitoring, federal and state regulatory guidelines, standards, and practices
by attending meetings, visiting other sites, reading, reporting and disseminating
relevant literature.


EDUCATION :
Master Degree in Public
Health, Nursing, or related field with an emphasis in epidemiology and/or health
services.

EXPERIENCE :
Five to seven years\u2019
experience in health care environment, including two (2) years\u2019 experience in
project management, research and evaluation of healthcare outcomes and three
(3) to five (5) years of management/supervisory experience.

SPECIAL SKILLS:
Excellent
interpersonal, communication and leadership skills. Ability to work
collaboratively and independently; demonstrated personal maturity and good
judgment. Expertise in data collection and process improvement techniques.
Expert knowledge of information systems and external databases associated with
accreditation and regulatory requirements for quality of care, treatment and
service evaluation and public reporting.

ACCOUNTABILITY :
Accountability for
planning, implementation and evaluation of departmental policies, budgets and
project plans. Provides technical and administrative guidance to senior management
on a project basis. Manage business plan goals, assures adherence to budgetary
constraints and goal setting. Manages the daily departmental operations and
provides feedback to department's Medical Co-Directors and CMO/Senior Vice
President as warranted. Assumes responsibility in the development and
maintenance of systems used to collect, analyze and report departmental data.

COMPLEXITY :
In personal and
job-related decisions and actions, consistently demonstrates the values of
integrity (doing the right thing), patient-centered (putting patients and
families first), respect (valuing all people and embracing all differences), accountability
(being responsible and taking action), and compassion (being empathetic). Responsible
for the development of the departmental budget. Facilitates collaboration
between department and hospital disciplines involved in the monitoring and
evaluation of quality improvement, patient safety and infection control
processes. Demonstrates and expert knowledge of hospital policies and
procedures, TJC Standards, CMS Conditions of Participation, CT State Health
Department Guidelines and other applicable State and Federal Regulatory
Guidelines.

LICENSURE/CERTIFICATION:
RN licensure preferred
but not required.

SPECIAL WORKING
CONDITIONS AND PHYSICAL DEMAND:

Walking and travel
between campuses and delivery networks is required.
*CB
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Job Info

Job: 10771

Department: Safety and Quality
Category: Mgmt/leadership
Status: Full Time
Shift: DAYS
Hours: 40.000

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