VP, Patient Safety & Quality - Northern Region


hackensack university med cntr Hackensack Requisition # 2018-53844 ShiftDay StatusFull Time with Benefits Weekend WorkWeekends as Needed HolidaysAs Needed On CallNo On-Call Required Standard hours per week40

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Overview

Reporting directly to the SVP, Chief Quality Officer, this position as the VP, Patient Safety & Quality for our Northern Region is the senior leader overseeing the HMH mission in all matters relating to patient safety and quality of care at a regional hospital level supporting Hackensack University Medical Center and Palisades Medical Center. This position works to eliminate preventable harm to patients, family members, and staff, to attain unsurpassed clinical and patient-reported outcomes, and build organization-wide participation through transparency, collaboration, and mutual learning. Working in partnership with senior administrative and medical staff leadership, the will oversee the institutional approach to quality and patient safety, and lead a comprehensive quality/performance improvement program.

The VP, Patient Safety & Quality for our Northern Region will lead the organization to achieve the strategic direction set by BOT to attain the highest publically reported public rankings in CMS, Leapfrog, US News and World Report, and others.

This includes the following areas of oversight:

  • Infection Prevention and Control
  • Public Reporting and Clinical Data Management
  • Patient Safety Committee work, root cause analyses, and requisite improvement
  • High Reliability
  • Peer Review
  • Care transitions/readmission reduction
  • Multi-disciplinary unit-based leadership teams
  • Clinical pathways and guidelines
  • Rapid Response Team (RRT) and Code Teams
  • Patient Blood Management (utilization)
  • All other quality/performance improvement initiatives

Responsibilities

Essential responsbilities for the position includes:

 

1. Assess and improve safety and quality across the system and create an environment in which staff trained in quality improvement work side by side with staff responsible for safety activities.

2. Imports new ideas and best practices and oversees their local application. All departments including nursing, pharmacy, MDs and others Executive operations.

3. As Chairperson of the Performance Improvement Department, this position will have the responsibility to implement a comprehensive data management system involving identification of all quality and safety metrics from throughout the organization, to include all public reporting measures and metrics from all existing databases and registries. These metrics will be reported through the Performance Improvement Coordinating Committee (PICC), by means of an automated dashboard system which will ensure accuracy and timeliness. This process will also provide for a more rapid analysis of data thus facilitating application of improvement efforts by accountable parties.

4. Assume a leadership role in assuring that quality and safety at all affiliate and network organizations will be maintained at a high level.

5. Creating clinical communities and joint quality and safety committees to begin collection and analysis of appropriate metrics by with creation of enterprise level dashboards that will assure system wide network transparency and establishing appropriate accountably for improvement initiatives utilizing safety science, reliability science and other PI methods and tools. This interaction is designed to maintain Hackensack Meridian Health's traditional brand of quality and spread improvement to an expanding population base in keeping with future institutional commitments.

6. Leads the organization to become a High Reliability Organization (HRO) by applying to healthcare basic principles used in other industries.

7. Leads the PICC and Patient Safety committee to establish comprehensive leadership level action committees to review all safety and quality issues and metrics and enable the committee to better recommend and assign priorities and resources. Monitors appropriate metrics to assure the effectiveness of this new structure

8. Continue the development of the existing CUSP units and lead efforts to spread this safety based program to all patient care units.

9. Responsible for implementation of a comprehensive safety program to include the NQF set of Safe Practices, the Joint Commission NPSG and the AHRQ Patient Safety Indicators.

10. Continues to pursue projects such as HQCE, the Kaplan and Porter model of deconstructing processes of care to better understand outcomes and cost of care, and reconstructing such processes, eliminating unnecessary variation that does not add value or improve resource utilization.

11. Leads collaborative initiatives such as the Cost/Quality Collaborative with IHI to improve efficiency and eliminate waste throughout the organization, while maintaining high quality.

12. Leads efforts to improve the CMS driven projects such as Value Based Purchasing and Readmissions and HACs reduction through the Partnership for Patients program.

13. Leads all patient safety and quality efforts for outpatient departments across the organization.

14. Leads the effort to establish collegially interactive Multi-Disciplinary Teams on all units and further develop the CUSP model for Patient Safety and move toward the production model of Quality Improvement where improvement efforts are included as a part of daily work.

15. Continues efforts to create and lead quality and safety improvement activities with affiliate organizations. Appropriate metrics will be reported through the system wide Clinical Integration Committee.

16. Establishes goals and develops metrics to measure quality and safety outcomes used in the determination of incentive plans. Some metrics may include readmissions, length of stay, 72 hour readmission, Clinical Core Measures and all Patient Indicator Compliance.

17. Pursues the introduction of Lean Techniques to reduce waste and increase value in processes of care.

18. Will interface with our Academic Affiliates, coordinating teaching and research efforts with quality initiatives.

19. Regulatory knowledge and experience (JCAHO) as needed.

Qualifications

Licenses and Certifications Required:

1. M.D. License or otehr Doctoral level degree

 

Education, Knowledge, Skills and Abilities Required:

1. Proven and progressive experience in Performance Improvement and Patient Safety.

2. Demonstrated leadership experience in a role within a major hospital and/or health system.

 

Education, Knowledge, Skills and Abilities Preferred:

1. Additional training in quality, MBA, MPH, or MHS preferred

2. Advanced Degree in Healthcare Business

3. Familiarity with, Lean techniques, the CUSP model for Patient Safety and High Reliability Organizations (HRO)