Director, Quality and Risk Management - Geisinger/St. Luke's Hospital Job at St. Luke's University Health Network
St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission
of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.
Join the Quality and Risk Management team that supports the region’s largest hospital system with over 18,000 employees in two states. The Geisinger/St. Luke’s Hospital located in Orwigsburg PA, provides availability of quality inpatient health care resources to residents of Schuylkill and Northern Berks Counties. This new campus will be located 9 miles north of Route 78, on Route 61 in Orwigsburg providing EASY access for our patients and visitors.
This position is responsible for all aspects of Quality, Clinical Risk Management, Infection Control and select specialty programs at the GSL campus. This individual will coordinate all performance improvement activities, facilitate process and/or system changes to enhance patient safety, and collaborate with the network Accreditation & Standards department to maintain regulatory compliance. This position interacts with all levels of the organization, supervises infection control preventionist staff and reports to the VP of Patient Care Services.
Professional Responsibilities:
Quality Resources/Performance Improvement
1. Facilitates quality goals set by leadership; assists in identifying benchmarks and opportunities for improvement; guides efforts towards attaining top decile performance and outcomes.
2. Provides education, consultative services and/or technical assistance to hospital departments, Performance Improvement Committees, Service Lines and Performance Improvement Teams.
3. Facilitates/leads organizational improvement activities utilizing the PDCA improvement methodology. Recommends tools and assists teams throughout the improvement process.
4. Conducts concurrent review of the literature and websites to provide teams and Service Lines with up to date evidence and best practice recommendations.
5. Works in a collaborative manner with physicians, administrators, department managers and others to identify and meet the continuous performance improvement requirements of the organization.
6. Collaborates with Decision Support staff to determine performance metrics for key process and performance improvement initiatives.
7. Analyzes data reports and implements process to achieve improved performance.
8. Conducts chart review for mortality and morbidity review.
Clinical Risk Management
9. Performs all functions of the Patient Safety Officer as required by Act 13.
10. Maintains facility-wide patient safety event reporting system.
11. Promptly investigates actual and potential clinical patient care events, including those events reported via the Patient Safety Hotline.
12. Analyzes actual and potential clinical risks for risk prevention and mitigation initiatives using root cause/intense analysis processes.
13. Collaborates with clinical and administrative colleagues to respond to regulatory and legal issues as they arise.
14. Responds to patient complaints as requested.
Accreditation and Standards
15. Participates / leads tracer activities in hospital departments.
16. Participates in environment of care rounds and works with department leaders to resolve noncompliant issues.
17. Assists with Joint Commission annual Periodic Performance Review by collecting data, organizing teams and assessing processes.
18. Designs and implements strategies to meet network accreditation and regulatory revisions and hospital plans for correction.
19. Participates as directed in licensure and accreditation surveys and complaint investigations as assigned.
Departmental Responsibilities
20. Fulfills administrative duties according to departmental policies/procedures including maintaining records for administrative and regulatory purposes and developing goals and objectives for the department.
21. Oversee and supervise the Infection Control Preventionist.
22. Prepares and manages the budget of the Quality and Risk Management Department, and Infection Control Department demonstrating an awareness of evaluating quality and cost/benefit outcomes.
MINIMUM QUALIFICATIONS
EDUCATION:
Registered Nurse (RN) with current license to practice in the state of Pennsylvania. Bachelor of Science Degree in Nursing preferred. Certification in Infection Control (CIC) preferred upon hire. New ICPs must proceed with certification after two years of full time employment or equivalent. Minimum of two years in acute care clinical nursing required.
TRAINING AND EXPERIENCE:
Minimum of two (2) years nursing experience in acute care clinical nursing.
WORK SCHEDULE:
Full time. Must be able to work flexible hours as needed.
Please complete your application using your full legal name and current home address. Be sure
to include employment
history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!!
St. Luke's University Health Network is an
Equal Opportunity Employer.
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