Reporting to the President & CEO, oversees all daily activities of Performance Improvement and Patient Safety programs; is responsible for implementing policies and procedures as required by the programs; is responsible for implementing policies and procedures as required by the Medical Center or external organizations related to Performance Improvement and Safety.

Education

Bachelor’s degree in nursing or healthcare related discipline required.Master’s degree in Nursing, Health Administration, Public Health, or other related field required.Certified Professional in Healthcare Quality(CPHQ) required or obtained within 18 months of hire

Experience

At least five to ten years in healthcare leadership roles with demonstrated experience in quality management, patient safety, and regulatory compliance.  Clinical chart review and abstraction experience preferred.Management experience required.Joint Commission knowledge and experience required.

Skills

Knowledge of State, Federal, and TJC requirements.Computer and Internet skills and experience required—familiarity and comfort with MS Office products is essential for success in this position (Word, Excel, PowerPoint and access).Analytical skills necessary to assess and correlate Performance Improvement data.Seeks opportunities to be present, visible, & approachable in the organization.Excellent interpersonal skills necessary to maintain good rapport and effective working relationships with medical staff, nursing staff and other hospital personnel.

Licensures, Certifications

Current State of Maryland license as a Registered Nurse, or other licensed clinicianCertified Professional in Healthcare Quality (CPHQ) required or obtained within 18 months of hire

Principal Duties and Responsibilities

Strategic Leadership:

Develop and implement a comprehensive quality and patient safety strategy aligned with the health system's overall goals and regulatory requirements.Foster a culture of safety, high reliability, and Zero Harm.Incorporate patient and family perspectives into quality and safety initiatives

Quality & Safety Oversight:

Ensure compliance with all regulatory standards and accreditation requirements (e.g. Joint Commission Standards, CMS Conditions of Participation (CoPs), state department of health regulations, or other accreditation standards)Identifies Sentinel Events and coordinates Root Cause Analysis.Implement evidence-based patient safety practices by staying up-to-date of best practices in patient safety and translating them into actionable policies and procedures across the health system.

Performance Improvement:

Direct the collection, analysis, and dissemination of quality and safety data to identify trends and areas for improvement.Prepares reports on Quality Assurance variations, actions and follow up when indicated.Works with the medical staff, nursing, other departments, and Quality Assurance Nurses in identifying, reporting and correcting identified Performance Improvement problems.Collates trends and analyzes all Quality Assurance data and distributes appropriately.Maintains up-to-date knowledge of hospital and nursing policies and procedures in order to identify deviations and set corrective action.Conducts patient safety rounds and analysis on each unit, providing timely feedback to managers and administrative staff when there are breaches in patient safety.

Stakeholder Communication & Collaboration:

Open, transparent, & strategic communicationServe as a liaison between executive leadership and clinical teams to ensure alignment on quality and safety priorities and initiatives.Develops and maintains effective relationships with other Hospital employees, the medical staff, patients and visitors to promote a positive response to the Hospital and a positive work environment.Provides education to all staff on the Patient Safety program, including education on the National Patient Safety Goals.Assist Risk Manager when requested in addressing liability concerns.

Department Leadership: 

Lead and mentor a team of quality, safety, and performance improvement professionals.Interviews, hires, orients, trains, and evaluates the performance of and disciplines and discharges subordinates.Promote a positive work environment that supports professional growth, innovation, and high performance.

Performs other related duties such as concurrent and retrospective focus review when necessary.Participates as a member in ad hoc study groups and assists with criteria development and abstracting.

Physical Requirements

Normal data abstraction/office environment

Working Conditions

Normal office work environment.

All roles must demonstrate GBMC Values

GBMC ValuesValue Description

Respect

I will treat everyone with courtesy. I will foster a healing environment.

Treats others with fairness, kindness, and respect for personal dignity and privacyListens and responds appropriately to others’ needs, feelings, and capabilities

Excellence

I will strive for superior performance in every aspect of my work. I will recognize and celebrate the accomplishments of others.

Meets and/or exceeds customer expectationsActively pursues learning and self-developmentPays attention to detail; follows through

Accountability

I will be professional in the way I act, look and speak. I will take ownership to solve problems.

Sets a positive, professional example for othersTakes ownership of problems and does what is needed to solve themAppropriately plans and utilizes required resources for various job dutiesReports to work regularly and on time

Teamwork

I will be engaged and collaborative. I will keep people informed.

Works cooperatively and collaboratively with others for the success of the teamAddresses and resolves conflict in a positive waySeeks out the ideas of others to reach the best solutionsAcknowledges and celebrates the contribution of others

Ethical Behavior

I will always act with honesty and integrity. I will protect the patient.

Demonstrates honesty, integrity and good judgmentRespects the cultural, psychosocial, and spiritual needs of patients/families/coworkers

Results

I will set goals and measure outcomes that support organizational goals. I will give and accept help to achieve goals.

Embraces change and improvement in the work environmentContinuously seeks to improve the quality of products/servicesDisplays flexibility in dealing with new situations or obstaclesAchieves results on time by focusing on priorities and manages time efficiently

Pay Range

$1,000.00 - $800,000.00

Final salary offer will be based on the candidate's qualifications, education, experience and alignment with our organizational needs.

COVID-19 Vaccination

All applicants must be fully vaccinated against Covid-19 or obtain a GBMC approved medical or religious exemption prior to starting employment at GBMC Healthcare, to include Gilchrist and GBMC Health Partners.

Equal Employment Opportunity

GBMC HealthCare and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.