Ingalls Memorial Hospital is seeking a seasoned and collaborative Director, Clinical Excellence to join us at our medical campus in Harvey, IL.
The primary function of this position will be to provide oversight of Quality, the Patient Safety Organization, Risk Management, and Regulatory Compliance, and the Infection Control Program. The individual in this role will work collaboratively with the President, COO, CNO, CFO, and senior System Leaders to execute on the organization's Patient Safety and Quality plan and will assist in setting the goals and priorities for the hospital under the Health System Patient Safety Plan. The Director will monitor and oversee various quality metrics, external rankings, pay performance metrics, patient safety investigations, pro-active risk management reviews, and the implementation of patient safety improvement plans. This leader will partner with the CNO during regulatory surveys to interface with the regulatory survey teams during site-visits. The Director oversees the creation, implementation, and submittal of any necessary regulatory plan of corrections, and will also set the annual infection control work plan. The Director will be instrumental in fostering relationships with key executive leaders across the organization and system, including physician and clinical partners. Must possess comfort in navigating a highly matrixed environment.
Who you are:
An individual striving to improve the lives of patients with:
- Bachelor's degree in a health-related field preferably nursing.
- Master's degree in related field preferred.
- Ability to work and communicate with all levels of staff as well as exceptional analytical and organizational skills.
- Hospital experience of at least 5-7 years in a clinical or administrative role with specific experience in dealing with patient safety, risk management and/or quality
- Experience in supervising, leadership, and management functions, preferred. Risk Management work experience of at least 5 years.
- Certified Professional in Patient Safety preferred.
- Certified Quality Management Professional preferred.
What you'll gain as Director, Clinical Excellence:
- Ability to support the philosophy and goals of the University of Chicago Hospitals.
- Knowledge of and participation in the University of Chicago Hospitals Pride Values.
- The ability to serve as a role model and driver of new technologies and new ideas.
What you'll do as Director, Clinical Excellence:
- Assists Vice President and Senior Executive Team in setting and implementing the institutional patient safety plan, infection control plan and goals for the fiscal year. As part of this process, conducts an annual assessment of the Safety, Risk Management, and Infection Control programs to set priorities and focus on new initiatives. Priorities will be based on external data and performance on national quality and patient safety metrics.
- Serves as a consultant to the senior leadership team on progress towards the Quality and Safety Plan. Facilitates the Hospital Quality Committee and Leads Executive Quality and Safety Huddle.
- Conducts root cause analysis meetings for all sentinel events and high risk systems issues identified by staff. Facilitate follow-up task force and committee meetings to address risk and safety issues identified. Conducts pro-active risk assessments for identified sections and departments on an annual basis. Link specific initiatives to reductions in patient harm events, claims frequency, and severity trends with the goal of reducing malpractice related expenditures. Supports Physician and Nursing Peer Review Process.
- Provides support and consultation services to all staff on a rotating schedule for pager coverage 24/7. Facilitate disclosure conversations with clinicians and patient/family members. Facilitates a patient safety and risk reduction annual education and awareness program. Conducts educational sessions for faculty and staff on risk and safety related topics.
- Leads Regulatory compliance visits with the Department of Public Health, DNV, TJC, CMS, and any other regulatory bodies. Directs the team during the survey, develops plan of correction (POC), oversees implementation of POC, and submits required evidence of completed POC to said body.
- Facilitates, prepares materials for and participates in hospital committees and M&M conferences representing Departmental issues and risk and safety concerns. Prepare materials for presentation at the UCMC Quality Committee.
- Performs other duties assigned.
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