Director Quality and Patient Safety, South Hospital - UofL Health

Overview

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.

Responsibilities

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

Qualifications

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

#LI-DNI