- St Joseph School Of Nursing
- $30,480.00 -42,550.00/year*
JOB TITLE:#Chief Quality and Safety Officer DEPARTMENT:#Quality Assurance REPORTS TO:#COO SUPERVISES:#Quality Improvement, Patient Safety, Infection Control, Accreditation, Risk Management POSITION SUMMARY: Responsible for planning, implementation, and evaluation of Quality Improvement (QI), Patient Safety Program, Infection Control, Accreditation, Risk Management to meet key hospital and organizational goals. Provides mentoring and education to the organization related to all categories above with a focus on clinical and medical staff .throughout the organization. Facilitates all efforts throughout the organization aimed at improving systems and processes for better outcomes. Ensures the organization is in #continuous readiness# state for Joint Commission. Ensures continued inherence to High-Reliability Organization (HRO) principles across the organization. Resource to administrative team, department managers and medical staff in all areas noted above. Ensures the organization is maintaining all Regulatory Compliance, e.g. Federal (CMS), State (DPH), Joint Commission) TJC, OSHA, etc. Supports Medical Staff departments and committees in their Quality, Safety, Patient Experience, and Peer Review efforts. Reviews, aggregates, and analyses internal and external data. Presents data in many venues for clear communication throughout the organization. Ensures public reporting of quality, safety, and patient satisfaction data. Conducts safety surveillance inspections and assures the hospital#s Safety and Security Management Plans comply with federal, state and local regulatory requirements. Manages staff in all areas of responsibility for maximum effectiveness and outcomes. EDUCATION/CERTIFICATION: Bachelors of Nursing or related field. Master of Science in Nursing, Quality, and Safety or Health Care related field. Certified Professional in Healthcare Quality (CPHQ) or obtain certification within 3 years of position. Lean Six Sigma and/or Quality Improvement Advisor training and certification required. EXPERIENCE: Minimum of 5 years of clinical practice. Previous Quality Improvement, Safety, Accreditation, Risk Management and/or Regulatory experience required. Knowledge and experience in Joint Commission readiness and on-site reviews Previous experience with High-Reliability Operations (HRO) principles required. Knowledgeable use of databases and spreadsheets. Strong leadership skills. COMPETENCIES: Adapts to and helps to facilitate change. Acts as a change agent for the organization. Follows all CKHS and departmental policies and procedures. Responsible for oversight of continuous readiness for Joint Commission (TJC)reviews and licensing. Helps lead and support organization during TJC site visits. Organizes own time well and uses resources efficiently. Demonstrates the ability to make accurate, strong and timely decisions. Displays enthusiasm, initiative, and awareness of needs throughout the organization. Displays motivation and energy to undertake and complete work independently. Delegates appropriately for best outcomes. Is forward thinking, using current evidenced-based practices and literature to develop new initiatives for maximum effectiveness and growth of the organization. Excellent communication and presentation skills#written and verbal. Confidentiality. ESSENTIAL DUTIES and RESPONSIBILITIES: Disclaimer: Job descriptions are not intended, nor should they be construed to be, exhaustive lists of all responsibilities, skills, efforts or working conditions associated with the job. They are intended to be accurate reflections of the principal duties and responsibilities of this position. These responsibilities and competencies listed below may change from time to time. Job-Specific Competency Develops, maintains and evaluates a comprehensive performance improvement program for the organization to ensure compliance with all regulatory requirements. Advises and educates the Local Advisory board, Senior Leadership medical staff and all levels of the organization regarding coordination and participation in QI programs to ensure that CKHS meets all TJC, DPH and any regulatory requirements. Responsible for all activities related to TJC continued readiness and accreditation. Responsible for timely reporting of key performance indicators including Value-Based Purchasing, Hospital Acquired Conditions, Patient Safety Indicators, reportable events, core measures and patient satisfaction to Senior Leadership, the Medical Staff and Board of Trustees. Provides educational programs related to Quality Improvement, Patient Safety, Accreditation, Risk Management and regulatory requirements to the organization. Coordinates evaluate, supports and participate in the Medical Staff Peer Review process with the Medical Affairs department and Medical Staff leadership. Supports attends and presents at the Local Advisory Board, Senior Leadership and Medical Staff committees. Creates and maintains the yearly Performance Improvement and Patient Safety Accomplishments and Goals including the Performance Improvement Plan update and Patient Safety Plan. Works with Biomedical and Engineering Department to ensure safety surveillance is completed on all construction projects and assists with the completion of the construction risk assessment. Ensures that the Annual Safety Report to include information specific to the Hospital#s Environment of Care. Prepared and presented to Quality Council, Senior Management and the Local Advisory Board Collaborates in reviewing, revising and distributing safety and hazardous communication policy updates when needed but at least once every three years. This includes the Safety, Security, Hazard Communication Plan#s objectives, scope, performance, and effectiveness annually, if needed. Collaborates with the Hospital#s Worker#s Compensation and Risk Management to assure that the Hospital#s occupational practices are in compliance with State, Federal and local regulations. Provides corrective action recommendations to department Directors and managers where it is felt corrective action will minimize risk to employee health and loss work time Ensures that all documentation and other criteria as required by all regulatory agencies are in place Manages and Supervises Accreditation and Risk Management for the organization for optimal effectiveness and outcomes. Oversight and management of the Infection Control department and staff with participation and support in all aspects of infection control for optimal effectiveness and outcomes.
Associated topics: bio, biology, biomedical, bioprocess, biosynthetic, hereditary, medical, msat, parenteral, therapeutic
* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.
Loading some great jobs for you...