Director Quality & Patient Safety Officer

Penrose-St. Francis Health Services is a full-service, 712-bed acute care provider in Colorado Springs comprising Penrose Hospital, St. Francis Hospital and St Francis Hospital - Interquest. St. Francis Hospital opened in 2008 to keep pace with the growing needs of the Colorado Springs' community on the north side of the city. St. Francis Hospital features 340-beds and offers a modern Birth Center, Level III Neonatal Intensive Care Unit, Cancer Center, Emergency Department, Level III Trauma Center, Imaging Services, Acute Inpatient Rehab, Surgical Services and Critical Care Unit. It also serves as southern Colorado's home base for the Flight For Life Colorado air medical transport service. It's an incredible time to join us as we celebrate recognition with Magnet Hospital designation from the American Nurses Credentialing Center (ANCC) for superior quality in nursing care. With more than 300 days of annual sunshine, mild winters and easy-to-access recreational areas including Pikes Peak, Garden of the Gods and some of Colorado's top destination resorts, you will enjoy an incredible lifestyle while having the career you've always wanted.

You have a purpose, unique talents and now is the time to embrace it, live it and put it to work. We value incredible people with incredible skills – but your commitment to a greater cause is something we value even more. This is the heartbeat of our organization and your time will be spent in a supportive, team environment with resources to help you flourish and leaders who care about your success.

Leads a multidisciplinary entity specific or multi entity quality program, including Clinical Quality, Patient Safety, Infection Control, Performance Improvement, Patient Experience and Regulatory Compliance in alignment with enterprise and operating or medical group priorities and guidance.

Job Responsibilities (essential functions)
• Functions as the entity specific or medical group Patient Safety Officer (PSO) – and is available to serve as the entity expert on quality or patient safety related issues. Has knowledge of resources to access to assist when needed.
• Oversees and coordinates all intradepartmental and interdepartmental services of Quality and Patient Safety.
• Develops, facilitates, and manages the entity specific or medical group annual QAPI plan, and maintains a quality reporting structure in accordance with the QAPI plan, regulatory requirements, and operating or medical group processes.
• Integrates and aligns quality work and processes which may include corporate and/or enterprise efforts.
• Collaborates and supports the process of developing, approving, and aligning policies and procedures for the entity and enterprise.

• Develops a mechanism for the internal communication of patient safety and quality information.
• Provides direction, coaching and support for all supervised associates to maintain their assigned job responsibilities.
• Uses various communication techniques on a regular basis, to exchange all information necessary and appropriate to efficiently and effectively fulfill duties.

• Support a "culture of safety" through the development of a transparent and data- driven/proactive/preventive facility Quality and Patient Safety Program that is reviewed and refined annually via the QAPI plan.
• Develops and maintains excellent working relationships with management, clinical directors, hospital executives, and medical staff or medical group leaders, and ensures that performance improvement efforts are prioritized and aligned with key quality priorities and strategic goals.
• Oversees the provision of transparent and comprehensive quality reports to the Board as applicable through the quality reporting structure that include patient and healthcare errors, near misses and/or dangerous conditions within the facility, and other regulatorily required information.
• Oversees the coordination of all hospital or clinic activities to ensure that the hospital or medical group clinics are always in a state of readiness to meet external agency requirements which may include NCQA.
• Provides on-site consultation which may include individual departments to assure that data is being used in quality improvement and risk management initiatives.
• Oversees the design and implementation of educational presentations that facilitate the understanding and implementation of all regulatory standards in the organization.
• Works collaboratively with either the enterprise Director of Quality Operations or Health Network (CHN) leaders to analyze and understand current state of quality data and speak to opportunities clearly.
• May coordinate / Co-Chair the entity specific Quality and Patient Safety Committee (QPSC).
• Promote and/or practice all components of the Lean and/or other PI methodology's, which may include the Health HRO toolkit or standardization throughout the facility for process improvement functions. Ensures all PI projects are reported through the quality reporting structure.
• Provides oversight in the analysis of occurrences and adverse events, and the reporting of learnings throughout the organization.
• Providing oversight and support in the analysis of HCAHPS data, development of reports, and related process improvement opportunities.
• Oversight and support for the management of patient complaints and grievances and/or may support resolution of patient grievances.
• Provides leadership, coaching and overall project support for continuous regulatory compliance with a focus on monitoring compliance and meeting requirement for all external regulatory standards.
• Mentors clinical managers in patient safety and risk reduction strategies to resolve issues found through occurrences or grievances.
• Provides oversight and support to the Infection Prevention Program Manager to ensure effective surveillance, actual and potential problem identification and resolution, and monitoring of clinical practice and consistent mandatory reporting
• Works collaboratively with entity and operating group or medical group leaders to recommend and facilitate change(s) to improve clinical quality and patient safety. Actively participates in professional organizations that promote evidence-based practices.
• Provides oversight for the development of the entity-specific Patient Safety Culture using High Reliability Organization principles.
• Ensures transparency and shared learning s across the entity, operating group, and enterprise. Provides oversight for a robust Infection Prevention program with an emphasis on excellent Hand Hygiene, and transparent and thorough data reports and action plans as facilitated by the Infection Prevention Program Manager, as applicable.

• Continually improves physician engagement with quality efforts through relationship development, ongoing education/communication, participation in MEC or physician leadership meetings, participation in Peer Review or payor credentialling as applicable, and by engaging physician champions for specific clinical improvement efforts.
• Active participation in the operating or medical group and enterprise efforts to create quality standardization, efficiencies, alignment and excellent quality care.
• Prepares department budget, including personnel, space allocation and resources necessary to provide required services.

Position supports both St. Francis Medical Center and St. Francis Interquest. 

In addition to bringing humankindness to the workplace each day, qualified candidates will need the following:

• Bachelor Degree required. 
• Master Degeree preferred. 
• 5 years' experience in a clinical healthcare environment with a focus on quality and safety.
• Two years leadership experience.
• Experience in clinical operations, performance improvement regulatory compliance, patient safety (including HRO concepts), and data analysis.
• Excellent communication, problem-solving, statistical and analytical abilities.
• Strong PC skills and knowledge.
• Strong presentation and facilitation skills.
• Certified Professional in Health Care Quality OR Certified Professional in Patient Safety - required at time of hire or within 6 months.
• Six Sigma or LEAN preferred.

Physical Requirements - Sedentary work - prolonged periods of sitting and exert up to 10 lbs. force occasionally