Director of Clinical Improvement and Risk Management / Patient Safety Officer
AdventHealth Fish Memorial
Location Address: 1055 Saxon Boulevard Orange City, Florida 32763
Top Reasons To Work At AdventHealth Fish Memorial
Immediate Health Insurance Coverage
Top Employer of Choice in Central Florida
Great benefits such as: Educational Reimbursement
Career growth and advancement potential
You Will Be Responsible For:
· Able to maintain credibility when communicating adverse news, follow through on promises and concerns, provide service recovery to dissatisfied customers, care about people as individuals and demonstrate empathy and concern while assuring that the organizational goals are met, accomplish objectives through influence, celebrate successes and accomplishments, and communicate a shared vision for the organization.
· Understands, articulates, and maintains accountability for organization risk management, infection prevention, quality assurance, performance improvement, and patient safety programs and plans in compliance with accrediting body standards, CMS Conditions of Participation, AHCA, and Florida State Statutes.
· Administrative oversight of the interview and selection process of new employees for the local Office of Clinical Effectiveness and Risk Management departments. Supervises the department leaders, performing employee performance evaluations as required, documenting employee performance and performing coaching and counseling as needed.
· Drive strategies to improve the outcomes as measured by CMS Value Based Purchasing Plan, CMS Star Ratings, Leapfrog Safety Grade and other publicly reported data.
· Facilitate the implementation of the organizational PI plan, ensuring universal participation and progress. Oversees committee and team meetings relevant to performance improvement and evidence based practice. Directs data collection, analysis, bench marking and related utilization of information systems to achieve quality initiatives.
· Directs and provides oversight for the activities of the Patient Safety/Ethics, Clinical Best Practice, Performance Improvement, Infection Prevention, and Medical Review committees
· Interact collaboratively with Administration, Medical Staff, Nursing and Ancillary Departments to promote a culture that encourages concurrent quality improvement and safety.
· Serves as Medical Staff liaison. Establishes and maintains productive working relationships with medical staff. Works in partnership with medical staff officers and chairmen to maximize committee performance. Ensures timely and relevant communication to all physician stakeholders.
· Ensures new employees and medical staff members are oriented in Quality Improvement, Infection Prevention, Risk Management, Just Culture, Accreditation and Patient Safety
· Serves as Patient Safety Officer for the facility
· Reports to the Board on performance improvement activities, risk management trends, risk reduction strategies to reduce patient harm, safety culture plans with goals, and publicly reported data with plans to improve.
· Active in the governance of the organization by presenting patient safety issues to the governing body, participating in strategic planning, and representing the local Office of Clinical Effectiveness at the organizations governing body.
· Provides administrative supervision to achieve and maintain ongoing accreditations compliance / TJC readiness.
· Delegates assignments and maintains accountability to achieve and maintain accreditation and quality-based certifications
· Directs activities to ensure data bases for accreditation, patient safety and quality are maintained, accurate and current
· Fosters an environment of service excellence for patients, families, physicians and community
· Develops and implements annual budget. Monitors and makes adjustments to meet effective use of budgeted resources and maintain fiscal accountability.
· Oversees the monitoring of opportunities for infection prevention and ensures staff are educated on policies and prevention guidelines
· Provide local oversight and support to region corporate responsibility through monitoring and audit plans
· Models shared-decision making in order to build collaborative relationships with executives, department directors, Board members, and the medical staff
· Accountable to executives and the Board for contract assessment and reporting
· Monitors and assures direct data analysis, trends, and review are compliant and timely
· Serves as a resource to the executive team and other departments for Patient Safety Initiatives, Performance Improvement, and Just Culture. Educates senior leadership teams in relation to patient safety and quality
· Oversight to physician peer review program and MRC
· Ensure AHCA annual report is completed and submitted timely
· Support patient safety organization and ensure data is submitted accurately and timelyQualifications
What You Will Need:
Bachelor’s degree in healthcare related field
Minimum five years’ healthcare management experience
Minimum three years’ experience in Quality, Compliance, Risk or Patient Safety
Minimum of five years acute care clinical experience
Experience and working knowledge of regulatory guidelines
RN with active Florida licensed
Licensed Healthcare Risk Manager (LHRM) (preferred)
Certified Professional in Healthcare Quality (CPHQ) (preferred)
Six Sigma Performance Improvement Certification (preferred)
Lean Performance Improvement Certification (preferred)
Certified Joint Commission Professional (CJCP) (preferred)
Certified Professional in Patient Safety (CPPS) (preferred)
The Director of Clinical Improvement & Risk Management / Patient Safety Officer provides leadership, direction and support for patient safety initiatives for the Central Florida Division – North Region and the designated local campus. This responsibility includes Risk Management, Quality, Infection Prevention, Physician Peer Review, Just Culture, Patient Safety Organization, Data Analytics, Performance Improvement and Accreditation. The scope of work includes establishing policies, procedures, strategies and objectives specific to assigned departments. Act as a liaison to the Medical Staff, Administration, all hospital Departments and committees to accomplish performance improvement and evidence based practice initiatives. Responsibilities include the assurance that the regulations of applicable Federal, State, and local regulatory and accrediting agencies and the Corporate Compliance Plan are adhered to.