Director Quality and Patient Safety, South Hospital - UofL Health
Shepherdsville, KY 40165
About the Job
We are hiring at UofL Health – South Hospital
Location: 1903 W. Hebron Ln.
Shepherdsville, KY 40165
Shift: Full time, 1st Shift
About Us:
UofL Health is investing in the health of Bullitt County, and the surrounding area with an expansion of UofL Health – Medical Center South to become an inpatient hospital – UofL Health – South Hospital. South Hospital is expected to open in early 2024 and will add approximately 100,000 square feet of new space to the existing facility. South Hospital will include a 10-bed intensive care unit, medical/surgical patient rooms, six operating rooms, new cardiac catheterization lab, expanded emergency department, centralized sterile processing area, laboratory, pharmacy, cardiopulmonary, respiratory therapy and more.
Benefits and Perks:
- Competitive Pay & Benefits Options.
- Paid Vacation, Sick days, and Holidays.
- Free tuition to UofL for Part- and Full-time employees for Child/Spouse/Domestic Partner.
- 401K with Employer Match.
Job Summary:
- Develops, operationalizes, maintains, and evaluates the Quality, Patient Safety, Clinical Performance Improvement, and Accreditation Program
- • Provides a comprehensive assessment of organizational needs to identify strategies to improve patient safety and clinical outcomes and serves as a leader in the on-going advancement of a “Just Culture” that promotes the non-punitive reporting of patient safety concerns
• Develops and assists others in developing action plans for process improvement and ensures follow through and loop closure on these plans
• Works in collaboration with the Physician Chairs, Nursing Directors, Executive Director Quality, CMO, CQO and Quality & Patient Safety Committee and any others to evaluate the effectiveness and appropriateness of care and development of policies and procedure
• Facilitates identification and documentation of hospital-based approved performance improvement variances and complications
• Analyzes Vizient and other program identified mortality and complications data on a regular basis to identify areas for improvement, education, and safety improvement activities
• Develops and coordinates of projects that will enhance the Performance Improvement, Peer Review, and Patient Safety Program - Leads multi-disciplinary projects related to the hospital’s overall goal to become a 5-star Vizient organization
• Leads the accreditation program in furtherance of continual Joint Commission readiness for the organization.
• Keeps informed of the Joint Commission requirements for triennial accreditation standards for Performance Improvement and OPPE/FPPE standards
• Completes case reviews and analyses for contributing factors to the variance in care and/or complications including all Serious Safety Events, deaths and complications.
• Facilitates the creation of physician-department Performance Improvement Committees and assists in preparing case reviews and projects for discussions
• Facilitates the semi-annual Leapfrog Safety Survey completion and all improvement activities surrounding this survey and any other publicly reported quality and patient safety data. - Serves as administrator of designated patient safety system. This will include training, managing the event database, and participating in all educational activities as required
• Leads the investigation of all sentinel incidents (to include performing a root cause analysis)
• Develops ongoing physician practice evaluation triggers
• Generates annual report information regarding activities and prepares statistical data
• Supports the Medical Staff departments in identifying and selecting opportunities for improvement and facilitates continuous performance improvement
• Facilitates Medical Staff Peer Review meetings and serves as a liaison between various committees to facilitate communication and referral of cases for further physician review, and report results back to referring committee
• Attends safety huddle to report any safety trends found in chart review
• Maintains compliance with all company policies, procedures and standards of conduct
• Complies with HIPAA privacy and security requirements to maintain confidentiality at all times
• Performs other duties as assigned
Required Qualifications:
- Bachelor of Science in Nursing
- Minimum five years of acute care, hospital-based clinical experience in area of intended practice.
Preferred Qualifications:
- Previous experience in academic teaching hospital
- Master of Science in Nursing or other healthcare related master’s degree
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