Initiates and oversees the development of a comprehensive quality improvement program; directs and coordinates in conjunction with the medical staff and system leadership, the quality initiatives for the facility
Fosters and maintains collaborative relationships with external agencies related to quality initiatives, including but not limited to purchasers, government agencies, and other stakeholders.
Initiates, oversees, and integrates a comprehensive medical safety program as an integral component of facility quality services; defines and coordinates the participation, Safety, Occupational Health Services, Risk Management, Quality Improvement Services, and others as necessary. Establishes relationships with external agencies related to medical safety programs, including but not limited to purchasers, government agencies, and other stakeholders.
Oversees a comprehensive Medical Safety Program in efforts to improve the safety of patients, visitors, and employees and makes recommendations for performance improvement activities related to medical safety. Oversees reporting of events as required by regulatory agencies in collaboration with Corporate Compliance/Risk Management/Legal Affairs/ HAAD standards. Coordinates and oversees data collection and analysis, reporting and improvement activities, and follow-up related to medical errors.
Oversees performance improvement (PI) activities in the facility, in collaboration with quality improvement staff and hospital leadership.
Leads the development of facility policies and procedures related to quality improvement and medical safety and participates as a stakeholder in the crafting of facility policies.
Oversees investigation and internal reporting of sentinel events and serves as physician champion in PI efforts related to medical safety.
Coordinate with the facility Quality committee and works with the committee to establish PI priorities.
Communicates PI and medical safety activities on a regular basis to the medical staff and engages medical staff in PI activities.
Reviews and evaluates services of the facility that are affected by quality/medical safety/regulatory issues, identifies problems, makes recommendations for improvement, and monitors services to ensure that safety/regulatory recommendations are implemented and the desired results are obtained.
Educates facility responsible individuals, facility leadership, and medical staff regarding regulatory issues, new statutes/guidelines, and performance improvement/medical safety activities/ HAAD standards.
Serves as a resource within the facility for performance improvement/ medical safety/regulatory issues and participates in activities related to JCIA accreditation.
In collaboration with clinical leaders, service chiefs, participates in the development, monitoring, reporting, and improvement activities related to clinical pathways and guidelines.
Sets system policy for organizational structure and collaborates in the approval of proposed structures. Develops long-range goals, annual objectives, and strategies for area(s) of responsibility.