The Director of Quality and Patient Safety (QPS) leads the development of a comprehensive and unified program of clinical quality, performance improvement, and patient safety in a challenging value-based healthcare delivery system. The Director works to sustain a culture of quality and safety, transparency, teamwork, measurement and accountability with clinicians and medical center team members. S/he works closely with the other AHS QPS Directors as well as the medical centers’ senior management, physician and nursing leadership, service line directors, infection prevention, Advisory Board members, and patients to instill continuous positive change in the organization’s quality and patient safety culture.

Job Responsibilities along with a percentage of time performing duties

• (30%) Quality Management Responsible for successful implementation of AHS quality and patient safety program within assigned medical center. Participates in the development and implementation of policies, programs and initiatives in order to improve the overall quality of patient care services. Partners with CMO’s, CNO’s, Department Chairs, Service Line Leaders, infection prevention, clinical staff and leadership to develop an efficient, intellectually rigorous, and engaging structure to encourage the alignment of their practice with the quality and safety agenda. Coordinate Quality Improvement Committee with assigned medical center and participates in system-wide and medical center committees.

• (20%) Process Improvement Provides oversight, support and/or consultative services (project design, selection of data required, development of documentation tools, etc. to quality improvement teams. Collaborates with the medical, nursing and other clinical leadership at the medical center to achieve excellence in metrics used by external rating organizations (CMS, Leapfrog, US News and World Report, Healthgrades, Vizient) Participates in the implementation of CMS bundle programs and other like-programs at the medical center to ensure success.

• (30%) Patient Safety: Leads the integration of high reliability organization (HRO) principles into the organization and supports the advancement of the organization and system in the HRO journey. Supports initiatives to improve the Culture of Safety including “Just Culture”. Collaborates with Legal/Risk Management to track and trend adverse events, conduct root cause analysis (RCAs) reviews, ensure the development and timely execution of complete and through risk mitigation strategies. Proactively identifies opportunities to eliminate risk using Failure Mode Effects Analysis (FMEA) and other proactive risk assessments.

• (20%) Regulatory Compliance: Establishes and implements systems and processes to ensure ongoing adherence to regulatory standards within assigned medical center. Maintains knowledge of Joint Commission, NJ Department of Health, and CMS clinical regulatory standards. Leads and coordinates all Joint Commission medical center accreditation surveys.

Supervisory Responsibilities

Provides direct supervision of the medical center Quality and Patient Safety (QPS) department team and collaborates with the AHS Infection Prevent Director in the oversight of the infection prevention department. Implements processes to support the ongoing competency and development of the QPS team members.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the required job qualifications. Reasonable accommodations. Reasonable accommodations may be made to enable individuals and with disabilities to perform the essential functions.

Other Desired Skills, Abilities, and Knowledge

• Proficient in the use of all Microsoft Office Applications

• Excellent written and verbal communication skills

• Strong organization skills and ability to multi-task various responsibilities

• Strong data analytic skills

Minimum Education and/or Experience Requirements

• Bachelor’s degree required (Nursing or health related field required)

• Master’s degree in a healthcare-related field or MBA

• 5 years’ experience in quality improvement or patient safety within a healthcare setting

• 3 years’ experience in leadership in a complex healthcare delivery system

• 3-5 years of clinical experience within an acute care hospital or health system

Required Licenses, Certifications and/or Registrations

• Certified Professional in Healthcare Quality or Patient Safety

• Current NJ Registered Nurse Licensure or Clinical Licensure (preferred)

ABOUT US

At Atlantic Health System, our promise to our communities is; Anyone who enters one of our facilities, will receive the highest quality care delivered at the right time, at the right place, and at the right cost. This commitment is also echoed in the respect, development and opportunities we give to our more than 20,000 team members. Headquartered in Morristown, New Jersey, we are one of the leading non-profit health care systems in the nation. Our facilities and sites of care include:

• Morristown Medical Center, Morristown, NJ

• Overlook Medical Center, Summit, NJ

• Newton Medical Center, Newton, NJ

• Chilton Medical Center, Pompton Plains, NJ

• Hackettstown Medical Center, Hackettstown, NJ

• Goryeb Children's Hospital, Morristown, NJ

• CentraState Healthcare System, Freehold, NJ

• Atlantic Home Care and Hospice

• Atlantic Mobile Health

• Atlantic Rehabilitation

We also have more than 900 community-based healthcare providers affiliated through Atlantic Medical Group. Atlantic Accountable Care Organization is one of the largest ACOs in the nation, and we are a member of AllSpire Health Partners.

We have received awards and recognition for the services we have provided to our patients, team members and communities. Below are just a few of our accolades:

• 100 Best Companies to Work For ® and FORTUNE® magazine for 15 years

• Best Places to Work in Healthcare - Modern Healthcare

• 150 Top Places to work in Healthcare - Becker's Healthcare

• 100 Accountable Care Organizations to Know - Becker's Hospital Review

• Best Employers for Workers over 50 - AARP

• Gold-Level "Well Workplace": Wellness Council of America (WELCOA)

• One of the 100 Best Workplaces for “Millennials” Great Place to Work® and FORTUNE® magazine

• One of the 20 Best Workplaces in Health Care: Great Place to Work® and FORTUNE® magazine

• Official Health Care Partner of the New York Jets

• NJ Sustainable Business

Named one of America's 50 Best Hospitals by Healthgrades, a World’s Best Hospital by Newsweek and recognized as a Best Regional Hospital in the NY Metro area by U.S. News & World Report.

Our Atlantic Neuroscience Institute is the region’s leader in neuroscience care. A hub for the New Jersey Stroke Network, we offer a broad range of advanced neurological, neurosurgical and neurodiagnostic services. We are also certified as a Level IV Epilepsy Center and home to the Gerald J. Glasser Brain Tumor Center, where more brain tumor surgeries are performed than anywhere else in New Jersey. Our CyberKnife® program is the largest and most experienced in the state. We also have a satellite emergency department in Union, NJ, which treats about 40,000 emergency cases each year.

Committed to providing exceptional care, Overlook Medical Center has achieved the prestigious Magnet® recognition. This designation from the American Nurses Credentialing Center is the highest national honor for nursing excellence. What’s more, Overlook Medical Center has advanced certification from The Joint Commission for perinatal care and is designated an Advanced Comprehensive Stroke Center. Additional Joint Commission-certified services include behavioral health care, spine surgery, wound care, and primary care medical home (PCMH).

EEO STATEMENT

Atlantic Health System, Inc. is an equal employment opportunity employer and federal contractor or subcontractor and therefore abides by applicable laws to protect applicants and employees from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment, on the basis of race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, citizenship status, disability, age, genetics, or veteran status.