Director, Safety & Quality, Long Term Care


HMH HOSPITALS CORPORATION Edison Requisition # 2021-101975 ShiftDay StatusFull Time with Benefits Weekend WorkWeekends as Needed HolidaysAs Needed On CallNo On-Call Required Shift Hours8:30am - 5pm Address343 Thornall Street, Edison, 08837

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Overview

How have YOU impacted someone’s life today?  At Hackensack Meridian Health our healthcare teams are focused on changing the lives of our patients by providing the highest level of care each and every day.  From our hospitals, rehab centers and occupational health teams to our long-term care centers and at-home care capabilities, our complete spectrum of services will allow you to apply your skills in multiple settings while building your career all within New Jersey’s premier healthcare system.

The Director of Safety and Quality assists with the planning, coordination, implementation and evaluation of the Hackensack Meridian Post-Acute organization-wide Resident/Patient Safety and Quality Improvement Program in accordance with Center for Medicare and Medicaid (CMS) and N.J. Department of Health regulations, the Hackensack Meridian Health network's processes, policies and procedures, as well as state / federal Patient Safety and Quality Improvement mandates. This role supervises Hackensack Meridian Nursing and Rehab (HMNR) and Hackensack Meridian (HM) Assisted Living facility resident/patient safety and quality improvement activities in compliance with the Hackensack Meridian Health network's processes, policies and procedures, as well as external regulatory requirements. The Director facilitates an interdisciplinary approach to the evaluation of identified problems and/or improvement of processes within each facility using the theories, methods, tools and principles of performance improvement, patient safety and high reliability.

Responsibilities

A day in the life of the Director of Safety & Quality at Hackensack Meridian Health can be described as follows:

 

  • Promotes a culture of resident/patient safety and coordinates the systematic implementation of an effective Resident/Patient Safety and Quality Improvement Program: Directs leaders and staff toward process /system improvements that will support the reduction of healthcare errors and other factors that contribute to unintended adverse resident/patient events and/or quality outcomes. Provides leadership for safety/quality assessments, oversees the activities of appropriate safety/quality committees, educates staff on the system-based causes for healthcare errors. Communicates literature-based ideas regarding effective patient safety/quality improvement strategies to assist others within the organization.
  • Facilitates the resident/patient safety review and analysis process: Reviews, analyzes and assists with the preparation of resident / patient safety event reports for submission to the HM Safety Event Classification (SEC) committee, Safety Council and other groups per HMH network's policies, procedures and processes. Facilitates and/or assists with Root Cause Analysis (RCA) and Apparent Cause Analysis (ACA) evaluations. Prepares and/or reviews and evaluates appropriate RCA/ACA reports for submission to the HMH Safety Council in accordance with network processes and timeframes. Reports patient safety and quality improvement activities to the HMH Safety Council and other patient safety/quality groups.
  • Assists with HMNR and HM Assisted Living patient safety and quality improvement activities: Maintains an organized system for patient safety and quality improvement review activities. Uses internal and external benchmark processes to evaluate performance. Collects resident/patient care data relative to issues and prepares summaries of review and evaluation activities. Assists with the development of improvement action plans and monitoring indicators to evaluate the effectiveness of any process or system changes implemented.
  • Facilitates an interdisciplinary approach to the evaluation of identified problems and improvement of processes: Facilitates interdisciplinary internal work groups to make positive changes with measurable outcomes and effectively communicates findings. Applies the theories of performance Improvement including statistical data to all patient safety and quality improvement activities.
  • Analysis of resident / patient safety and quality improvement data: Retrieves and utilizes pertinent data from the clinical, financial and performance measurement information systems. Analyzes performance measurement data, identifies patterns and trends for improvement and follows up as needed.
  • Data management and analytics: Track, analyze and report on relevant data and metrics as needed and/or requested. Develop, recommend and/or implement actions or process improvements as appropriate.
  • Maintains and updates records of all resident/patient safety and quality improvement activities: Enters resident/patient safety event and RCA/ACA data into the HMH Patient Safety database per HMH policies, procedures and processes. Maintains records of all resident/patient safety and quality improvement activities including minutes, correspondence and referrals to other committees in accordance with organization record retention requirements.
  • Educates leaders/staff on patient safety and quality Improvement: Educates leaders/staff on the theories, methods, tools and principles of performance improvement, patient safety, RCA/ACA and high reliability, as well as the HMH Patient Safety / Quality Improvement processes, policies and procedures.
  • Maintains up to date knowledge for the practice of performance improvement, patient safety, and high reliability: Maintains a current understanding of the theories, methods, tools and principles of performance improvement, patient safety and high reliability, including statistical data collection and analysis.
  • Maintains up to date knowledge of regulatory requirements and changes: Stays a breast of all regulatory compliance changes and incorporates findings into all resident/patient safety and quality improvement activities accordingly.
  • Participates in external regulatory agency survey activities: Participates in the planning and preparation activities for regulatory agency surveys. Promotes the understanding of compliance with current regulatory agency standards / requirements. Serves as a resource during the surveys regarding compliance with regulatory standards / requirements.
  • People management: Manages and/or assists in the recruitment, development and supervision of team members. Creates and sustains an environment that fosters team member engagement. Establishes clear objectives tied to organization and/or facility strategic goals. Coaches, counsels and evaluates performance of direct reports, as appropriate.
  • Other duties as assigned: Completes all other assigned duties and projects in a timely fashion.
  • Adheres to HMH Organizational competencies and standards of behavior.

Qualifications

Education, Knowledge, Skills and Abilities Required:

  • Bachelor's degree in healthcare related field required.
  • A minimum of 5 years clinical experience in healthcare required including knowledge of the complexity of healthcare systems and processes.
  • Excellent organizational skills.
  • Ability to manage multiple tasks and projects.
  • Effective verbal, written and presentation communication skills to develop and present reports and educational materials.
  • Strong interpersonal skills to interact with all levels of the organization.
  • Demonstrated ability to foster teamwork and bring diverse groups together in a collaborative and effective manner
  • Demonstrated analytic skills.
  • Ability to review and analyze patient safety-related events.
  • Ability to understand healthcare data and interpret and report results.
  • Demonstrated computer skills

Education, Knowledge, Skills and Abilities Preferred:

  • Bachelor's degree in Nursing or Master's degree preferred.
  • Experience in patient safety event investigation and root cause analysis, as well as working knowledge of patient safety principles and techniques desired.
  • Experience in quality improvement, as well as working knowledge of performance improvement theories, methods and tools, as well as data analysis desired 

Our Network

Hackensack Meridian Health (HMH) is a Mandatory COVID-19 and Influenza Vaccination Facility

As a courtesy to assist you in your job search, we would like to send your resume to other areas of our Hackensack Meridian Health network who may have current openings that fit your skills and experience.