About this Job

General Summary of Position

MedStar Southern Maryland Hospital Center is currently seeking a Senior Director of Quality & Safety to join their team. The Senior Director of Quality and Safety is responsible for planning organizing and managing the coordination of the organization's performance in clinical quality patient safety and risk management including related improvement activities required measurement reporting and monitoring. The Senior Director's responsibilities also include facilitating cross functional teams and the development and maintenance of a project management infrastructure to support improvement of quality and safety outcomes. Functions as the hospital risk manager providing risk identification and control through analysis of incident patterns and cases involved in litigation. Communicates needs and revised program objectives to hospital management to system quality and safety leadership and to risk management leadership. The position has a dual reporting responsibility to the system VP of Clinical Quality and to the hospital CMO/Vice President of Medical Affairs.

Primary Duties and Responsibilities

Leads hospital efforts to achieve top percentile performance in pay-for-performance and reputational quality programs. This includes major payor pay for performance programs such as the Maryland HSCRC Commission's quality-based reimbursement (QBR) Readmissions Reduction Program and Maryland Hospital Acquired Conditions. This also includes leading reputation measures such as Leapfrog US News and World Reports and Hospital Compare STAR ratings.
Supervises the following departments or functions: clinical quality patient safety patient relations risk management.
Develops and contributes to the achievement of established department goals and objectives and adheres to system hospital and department policies procedures quality standards and safety standards.
Provides education and orients hospital/medical staff with regard to quality and safety performance. Implements and monitors the quality performance measurement and performance improvement programs.
Provides oversight and subject matter expertise in clinical quality measures such as HAI PSIs mortality and readmissions with a focus on the defined system quality KPIs.
Assures data integrity and reporting for the MHA State of Maryland Core Measurement publicly reported data sources and other external databases.
Mentors and evaluates staff; and provides direction for departmental operations. Provides the oversight and maintenance of a comprehensive user friendly outcome management database examining the data for accuracy and updating the program to meet changing database needs. Keeps abreast of new methodologies processes management and organization trends best practices and emerging philosophies in the fields of performance measurement and organizational development.
Analyzes and interprets reports results of the hospital's performance efforts and matters relating to quality safety and provides advisement and Q&S-related leadership recommendations to the Vice President Medical Affairs system Q&S leadership and other administrators as requested.
In collaboration with the AVP for Health Equity responsible for identification and reduction of health disparities in Quality Key Performance Indicators at the entity.
In close collaboration with the system risk management leadership functions as the hospital risk manager providing risk identification and control through analysis of incident patterns and cases involved in litigation. Communicates needs and revised program objectives to hospital management to maintain the Risk Management Program.
Acts as the designated hospital liaison to the MedStar Risk Management program and other liability carriers for preparation of cases undergoing litigation and when legal or liability consultative information is required. Provides in-service education and orients hospital/medical staff with regard to Risk Management. In accordance with the Risk Management Plan administers the variance reporting system conducts investigations compiles and analyzes data to identify trends.
Leads ongoing management of patient safety events (PSEs) with significant risk or harm including SUOs and SSEs.
Performs and oversees event reviews using the MedStar Health event review process for all SSEs and SUOs as determined in coordination with the system AVP Patient Safety. Ensures necessary peer reviews are completed for these cases and support the implementation resulting mitigations and monitoring for effectiveness and sustainability.
Together with the System Safety Team initiates proactive risk identification and mitigation.
Continuously assesses and executes a safety culture program aligned with the MedStar Health approach. Leads key safety culture initiatives and ensures hospital compliance.
Oversees assessment of data to proactively anticipate major risks and works locally and with the system to develop effective and sustainable solutions to improve patient safety.
Actively participates in committees such as risk management safety and quality committees and quality councils and actively contributes to the work and execution of these committees.
Collaborates with the hospital VMPA/CMO and CNO the Medstar Health Risk Management and Patient Safety Leadership and MMG leadership to execute risk reduction for priority safety initiatives.
Responsible for management of the Department's daily operations to maintain quality fiscal productivity and patient satisfaction goals including additional objectives established by upper management.
Responsible for staff performance and meeting all departmental responsibilities. Responsible for providing high-quality service to and acting as a liaison to patients and their representatives physicians and employees. Responsible for optimum use of Department resources to maximize productivity and minimize costs.

Minimal Qualifications

Education

Master's degree in administration or healthcare related field required.

Experience

3-4 years In accreditation /regulatory affairs/performance improvement/patient safety in health care required.
5-7 years Managerial experience required.
Experience with or knowledge of risk/safety event reporting software preferred.

Licenses and Certifications

Certification in Quality preferred
Patient Safety Officer Certification preferred

Knowledge Skills and Abilities

Ability to comprehend and follow the policies and procedures for MedStar Southern Maryland Hospital Center.
Ability to read write and speak or communicate in English to successfully accomplish the essential duties of the position.
Ability to demonstrate ethical behavior that supports the hospital's mission values and commitment to compliance with all federal state and regulatory laws. Inspires trust and exhibits honesty and integrity within the scope of daily activities.
Exhibits professionalism courtesy and excellent customer service while interacting with patients guests and co-workers.
Ability to work effectively with people from a variety of culturally diverse backgrounds.
Ability to maintain patient confidentiality knowledge of risk management principles and issues regarding patient safety.
Knowledge and skill to demonstrate strong leadership and management qualities (task completion delegation motivation supervision).
Knowledge of accreditation standards health care regulations performance improvement and methods patient safety and policy formulation.
Ability to work with a variety of disciplines and levels of staff across department and the health system is required.
Effective organizational oral and written communication skills problem solving program development computer skills strong leadership and team building skills.
Knowledge of continuous quality improvement processes and methodologies Joint Commission Standards and CMS Conditions of Participation.

This position has a hiring range of : USD $134,118.00 - USD $265,616.00 /Yr.

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Senior Director Quality & Safety