Director of Quality & Patient Safety

Overview

Join our team as a day shift, full-time, Quality & Patient Safety, Director of Quality in Montclair, NJ.

Why Join Us?

Thrive in a People-First Environment and Make Healthcare Better

• Thrive: We empower our team with career growth opportunities, tuition assistance, and resources that support your wellness, education, and financial well-being.
• People-First: We prioritize your well-being with paid time off, comprehensive health benefits, and a supportive, inclusive culture where you are valued and cared for.
• Make Healthcare Better: We use advanced technology to support our team and enhance patient care.
• Learn more about the benefits offered for this job.

Get to Know Your Team

• Hackensack Meridian Mountainside Medical Center is an 820,000-square-foot facility that offers the latest medical programs, cutting-edge technology, and patient-focused care that includes 365 beds, 1,200+ employees and a 27-bed Emergency Room/Fast Track Unit.

Responsibilities

• The Director of Quality will lead and direct quality management activities as required by regulatory and accreditation standards.
• He/she will collaborate across teams to establish and implement strategic plans to improve quality outcomes, state measures of quality, and measures of health plan customer and provider satisfaction.
• In addition, he/she will oversee the management and execution of the annual HMH Mountainside Medical Center Patient Safety Plan, serve as a subject matter and analytic expert in quality and performance improvement for providers and groups, and lead/mentor Quality Improvement teams.
• Lead and guide progress of quality initiatives in collaboration with committee membership by Chairing: Patient Safety Committee, Administrative Policy Committee, and Clinical Alarm Risk Analysis.
• Manage the collection and analysis of clinical data for review and submission in compliance with federal, state, and accreditation entities.
• Formulate policy and make recommendations for final approval by the Administration.
• Support Joint Commission/CMS/NJDHHS survey readiness.
• Facilitate FMEA on an annual basis by selecting process/system issues based on trending of safety issues and recommendations at various committee levels (i.e., Patient Safety Committee), along with electronic event reports; preparation and retention of FMEA report, including action plan and implementation.
• Facilitate Internal Root Cause Analysis for those events for which mandatory reporting is not required; perform case review and prepare necessary documents for meeting; prepare action plan; transcribe and retain meeting minutes.
• Responsible for the Leadership and Patient Safety Systems chapters of the TJC manual-ensuring that proper information and documentation (if applicable) is available to demonstrate compliance with regulatory standards and elements of performance.
• Support staff with problem-solving of medical care quality and safety-related issues with providers.
• Facilitate annual Clinical Alarm Risk Analysis in compliance with TJC National Patient Safety Goals by organizing the committee, assessing results of surveys and questionnaires, and reporting back to all appropriate individuals to ensure a safe environment.
• Work closely with the Patient Satisfaction Coordinator, addressing quality concerns or grievances, assuring that the standard of care was met, and supporting a transparent approach to disclosure.
• Refer nursing quality and safety trend concerns to the Nurse Practice Council to improve the standard of nursing care provided.
• Work closely with HIM by monitoring reported hospital-acquired conditions with record review before coding to ensure accuracy in assigned POA or HAC status; utilizing physician expertise when inherent conditions exist, and exclusions apply.
• Prepare annual reports for the governing board on specific quality metrics via the VP, Chief Quality Compliance Officer.
• Prepares reports and maintains logs for Restraint-Related Death Reports; submits reports to CMS and maintains log and files.
• Perform any and all other duties assigned.

Qualifications

Job Requirements

• Bachelor’s degree in nursing.
• Current and valid nursing license.
• At least 5 years of experience in leadership, demonstrating progressive change management skills in a hospital setting with proven outcomes in quality-related roles
• Certification in health care quality, patient safety.
• Strong knowledge of quality measures and quality/compliance standards of accreditation.
• Excellent analytic and presentation skills to varied clinical and executive-level audiences.
• Proficient in Microsoft Word, Excel, Power-Point Point and Publisher.
• Demonstrates broad-based clinical experience and analysis knowledge, data aggregation, and qualities of leadership and sound judgment.
• Skilled in the art of human relations, problem solving, and conflict resolution/negotiation.

Preferred Job Requirements

• Master’s degree.
• A related technical specialty.

Rate of pay is determined based on experience and education and may include other pay components such as differentials and call pay based on role.