Job Description The Director of Quality and Patient Safety provides strategic and operational leadership for the hospital-wide Quality Assessment and Performance Improvement (QAPI), Patient Safety, Regulatory Readiness, Accreditation, and Quality Measurement programs. The Director partners with executive leadership, the governing body, medical staff, nursing, ancillary departments, and contracted clinical services to improve clinical outcomes, reduce preventable harm, ensure regulatory compliance, and advance a culture of safety and continuous improvement. This position serves as Senior Leader and collaborates with the Senior Leadership team on strategic planning, goal setting, department evaluations, and the implementation of strategic initiatives for the respective departments.

Essential Functions:

Initiates and oversees the development of a comprehensive safety and quality improvement, inclusive of the analysis and trending of data related to initiatives. Provides strategic oversight quality improvement committees with accountability for distribution of organizational communication vertically and horizontally within Lakeside Medical Center and vertically with the Healthcare District key leadership team as appropriate. Initiating and overseeing proactive evaluation and redesign of systems to improve care processes to prevent future errors. Provides overall direction necessary to ensure that clinical services are provided in accordance with standards established through state and federal regulations and The Joint Commission accreditation standards including the National Performance Goals that are evidence-based. Works with Key Leadership and Risk management Team to facilitate process change. Assesses compliance with accreditation standards and regulations related to clinical care in collaboration with entity leadership and staff. Identifies areas of vulnerability and directs the development of strategies to enhance compliance. Performing Patient Safety Rounds that establish psychological safety and empowerment to staff to identify and participate in resolution of patient safety concerns. Ensuring that information is submitted for public reporting in a timeframe required. Providing analysis and identifying trends utilizing EHR data. Assesses and reports quality indicator outcomes as appropriate to the facility and line of service. Designs education as needed to enable areas of responsibility to utilize quality data. In collaboration with clinical staff and service managers, participates in the monitoring, reporting, and improvement activities related to clinical care, health care quality/safety initiatives, accreditation and regulatory requirements. Coordinates the facility's Joint Commission accreditation activities including leading teams and committees in compliance activities. Provides leadership education on standards and coordinates ongoing compliance review activities and corrective actions. Coordinates all Joint Commission reporting. Participates and coordinates various committees and projects to facilitate the compliance of regulatory requirements. Regularly communicates quality/safety activities to leadership and staff. Emergency duty may be required of the incumbent including but not limited to: working in special needs or Red Cross shelters, performing other emergency duties responding to threats or disasters, man-made or natural as required. Provides operational leadership for the hospital-wide

CMS QAPI

program. Provide oversight for IQR, eCQMs, CMS Care Compare, HAC/PSI, mortality/readmission, SEP-1 and applicable outpatient measures. Provide oversight of quality performance for contracted patient-care services. Demonstrates understanding of PDSA, Lean, RCA, FMEA, statistical process control and sustained-control monitoring. Demonstrate ability to partner with Patient Experience to improve HCAHPS.

Qualifications Education:

Master's degree in nursing, healthcare administration, public health, quality, business administration, or related healthcare discipline preferred.

Experience:

Five (5) years of progressive administrative leadership experience in quality and patient safety activities with demonstrated ability in design and implementation of performance improvement activities in a health care setting including skillful application of continuous quality improvement and patient safety sciences. Responsible growth in acute care facility required. Experience in Lean-Sigma as an improvement methodology is preferred.

Certification:

Certified Professional in Healthcare Quality (CPHQ) preferred at hire; required within two years of appointment."

Training:

Executive, leadership and health care management training is preferred. About Us The Health Care District of Palm Beach County is an independent special taxing district that has served as a healthcare safety net for more than 36 years to fill in gaps in access to healthcare services. This unique healthcare system covers the entire county and provides a wide range of services such as nine community health centers (Federally Qualified Health Centers) which serve everyone regardless of ability to pay; school health teams in 172 public schools; a lifesaving Trauma Hawk aeromedical helicopter program; a rural, public teaching hospital, Lakeside Medical Center; an award-winning skilled nursing center; a ground ambulance program for Health Care District patients needing a higher level of care and the county's Trauma Agency, which ensures quality outcomes within the county's trauma system and leads initiatives to prevent traumatic injury. We are committed to a policy of Equal Employment Opportunity and will not discriminate against an applicant or employee on the basis of race, color, creed, religion, military or veteran status, age, sex, pregnancy status, genetic information, national origin or ancestry, citizenship, physical or mental disability, marital status, sexual orientation or identification status, or any other legally recognized category protected by jurisdictional, state or federal law. The information collected by this application is solely to determine suitability for employment, verify identity and maintain employment statistics on applicants. We are also committed to maintaining a safe, healthy, and productive work environment for all employees. As such, we are a Drug-Free Workplace. The Health Care District of Palm Beach County is an E-Verify participating employer and will use E-Verify to confirm the employment eligibility of all newly hired employees. This role may require Agency of Health Care Administration (AHCA) background screening and clearance. As required under House Bill 531, applicants may review AHCA's education and awareness information at the following link: https://info.flclearinghouse.com/