Director, Quality Initiatives & Improvement

Director, Quality Initiatives & Improvement

BAYSHORE MEDICAL CENTER
Holmdel, New Jersey

• Requisition #
• Shift: Day
• Status:
  Full Time with Benefits

Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It’s also about how we support one another and how we show up for our community.

Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change.

• Provides leadership to all safety and quality improvement activities at a hospital including committee meetings, medical staff peer review, root cause and apparent cause analyses, event management, morning safety report, follow up of ONELink event reports, and specific improvement cycles.
• Provides leadership to local HRO transformation. Engages all levels of leadership, caregivers and staff in advancing patient safety through HRO training, morning safety huddles, and joint event management with the departments of Human Experience and Risk Management
• Develops and oversees organizational quality initiatives and the monitoring of quality priorities.
• Presents quality data results with analysis and recommendation to a variety of organizational committees and councils including Department of Patient Care to enhance achievement of HMH quality goals.
• Oversees all quality improvement staff and their work in quality councils, teams and committees. Ensures that their team members achieve certification by the National Patient Safety Foundation as a Certified Professional in Patient Safety (CPPS), attend conferences, and receive continuing education including presentation skills, project management, process mapping, and lean principles. Cultivates and promotes continuous learning inside and outside of the network.
• Ensures compliance with all federal and state regulatory and licensing requirements, including aspects of Joint Commission readiness.
• Directs root cause and apparent cause and common cause evaluation of events and follow up activities. Identifies events, near misses and opportunities for quality and system improvement through the use of event reports, morning safety huddles, and trends identified through data analysis. Presents risk reduction strategies and follow up at Patient Safety Council to facilitate shared learning and scalability where possible.
  
  Identifies appropriate metrics to track meaningful change.
• Guides continuous learning and transparency related to patient safety and quality initiatives
  - Incorporates continuous learning including evidence based best practices, scalable system improvements, safety stories with lessons learned and needs identified through claims, suits and events. Through analysis of data, distinguish isolated events from trends and deploy resources to address those impacting patient experience, outcomes and ROI. Engage all levels of caregivers and staff in advancing patient safety through HRO training, quality initiatives addressing small wins and when designing system improvement.
  
  Utilize a variety of modes to increase the reach including webinar, video conferencing and interactive presentations.
• Guides hospital work in achieving HMH annual and strategic quality goals.
• Participates as a non‑voting member in the Hospital Peer Review Committee, where applicable. Leads initial case screening prior to submission to the committee.
• Ensures use of appropriate methodologies and relevant tools to achieve rapid cycle improvement (i.e. PDSA, FMEA, reliability science, bundle science, process flows).
• Collaborates with the Patient Safety and Quality Department as well as with the VP, Chief Quality/Safety to ensure that organizational wide safety and quality initiatives are implemented effectively and risk reduction strategies implemented wherever appropriate.
• Ensures effective analysis of performance data with comparison over time and comparisons to internal and external benchmarks to identify improvement…