Current UPHS employees must apply HERE
Director Clinical Effectiveness and Quality Improvement - Penn Medicine Princeton Health
Job ID: 162530
Work Type: FT
Location: Plainsboro, NJ, United States
Date Posted: Nov 29, 2022
Work Schedule: Days
Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.
Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?
- The Director of Quality is responsible for directing and coordinating the development, implementation, and maintenance of continous quality and performance improvement. This includes directing and/or assisting various departments with compliance of federal and state regulations as well as accreditation standards.
- Reporting to the Penn Medicine Princeton Health Vice President and Chief Medical Officer (CMO), the Penn Medicine Princeton Health (PMPH) Director of Quality provides leadership and oversight of the Performance Improvement Department and directs the execution of the strategic imperatives to support quality improvement and Penn Medicine's path to becoming a high reliability organization (HRO). Using the Blueprint for Quality as the key framework for action, this position works across clinical departments, UPHS entities and the continuum of care to assure that we provide the highest quality of care and experience to our patients and prevent unnecessary harm to all patients across PMPH. This position coordinates the PMPH Clinical Effectiveness Teams (CETs), supports quality improvement initiatives of the medical and nursing staff; as well as facilitates local quality improvement efforts of the Penn Medicine Service Lines and system-wide collaboratives. The position manages the daily operations of the Performance Improvement Department including policy and procedure development, staffing, scheduling, payroll, and ensuring efficient and thorough completion of the key activities of the department. This position has visibility across the organization and routinely interacts with all levels of staff and management. This position works closely with the UPHS Chief Quality Officer, the PMPH Chief Medical Officer, the PMPH Patient Safety Officer, Director of Safety, Infection Control Department, and other entity Quality Directors to provide input on strategy, participate in decision-making related to key quality issues, and assure dissemination and spread of successful quality improvement projects. In addition, as it relates to quality and regulatory matters, the position works with the following corporate departments: Risk Management/ Legal, Quality and Patient Safety, the Penn Medicine Academy, Health Information Management (HIM), the Office of Medical Affairs (OMA), and the Office of General Counsel. This position has direct managerial and leadership oversight of managers and analysts within the Performance Improvement Department. This position provides leadership and strategic direction to PMPH in all aspects of continuous survey readiness for CMS, The Joint Commission, NJ Department of Health and other regulatory and accrediting organizations. This position will work with entity senior leadership as well as directors within the organization to establish processes that optimize outcomes, minimize citations in a cost-effective manner and ensures adherence to CMS standards and state regulations.
- Directs the development and leads complex interdepartmental performance improvement projects that address identified gaps in performance or aspirations for higher levels of outcomes.
- Leads the assessment and action planning of all relevant internal and external comparative data for quality relative to patient care and patient experience outcomes to support the local and UPHS goals.
- Continually monitors the external environment for changes/new developments that affect quality. Collaborates with leadership to make proactive changes to the organization to ensure we are on track to meet the changing environment.
- Works closely with Princeton leadership, namely the CMO and Director of Safety to execute in planning and implementation of HRO framework central to our path towards becoming an HRO.
- Advises the Risk Management Program, inclusive of ensuring the release of records in response to subpoenas, insurance, or attorney requests, collaborates with appointed hospital legal counsel regarding the investigation of forthcoming proceedings and/or to prepare for pending litigation, ensuring interviews/depositions occur timely to prepare defense claims against the hospital, events entered into Origami, Penn Medicine’s potential compensable event database. Ensures necessary information is provided to the liability insurance carrier regarding all potential and verified claims.
- Directs the serious event management processes. Ensures thorough and credible root cause analyses of sentinel events or near misses with follow-up actions, and ensures monitoring by assigned clusters, committees and medical staff departments. Oversees the reporting of sentinel events to the New Jersey Department of Health and The Joint Commission.
- Provide organization wide leadership in continuous survey readiness for The Joint Commission and ongoing compliance with state, federal and other regulatory agencies.
- Directs the completion of accreditation, certification and other such applications, Intercycle assessments and data submission requirements. Works collaboratively to coordinate the development, submission and monitoring of plans of correction to resolve regulatory findings. Holds department leaders and process owners accountable for the timely completion of plans of correction. Supports understanding and participation of hospital personnel in advance of and during regulatory and accreditation surveys.
- Supports UPHS and PMPH strategic plan for implementing tactics and achieving goals in establishing and maintaining a high-reliability organization at PMPH.
- Work alongside Medical Director for Performance Improvement and The CMO to develop reporting calendars, agendas, and supporting materials for CEQI Committee, BOT Quality Committee, Patient Safety Committee, and other quality & regulatory-related committees.
- In conjunction with PMPH Health Information Management (HIM), Corporate CEQI HIM, PMPH CDI Team, Department of Medicine and the Performance Improvement team ensure accurate coding of comorbidities and present of admission conditions.
- Collaborates with UPHS entity colleagues, Department Directors, Managers and Clinical Effectiveness Teams (CET’s) to support survey readiness and ongoing regulatory compliance.
- Provides education, guidance and support to the Senior Leadership team (e.g. Vice Presidents, Directors, Managers, Medical Executive Committee) and staff regarding all regulatory and accreditation matters.
- CRNP or MD or RN (Required)
- Active NJ license in one of the specialties: MD/DO, PA-C, APN, or RN required
- Cert Prof in Healthcare Qlty
- Certified Professional in Healthcare Quality (CPHQ)
- Cert Professional in Healthcare Risk Management
- Certified Professional In Health Care Risk Management (CPHRM)
- Certified Profess in Pat Sfty
- Certified Professional in Patient Safety (CPPS)
- Lean Certification
- Six Sigma Green Belt / Lean Certification or Penn FOCUS PDSA
Education or Equivalent Experience:
- Master of Arts or Science (Required)
- Master's degree in Nursing, Health Care Administration, Safety/Quality or other relevant field of study
And 8+ years Experience as a health care provider and in managing quality and patient safety programs in a health care environment.
We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.
Live Your Life's Work
We are an Equal Opportunity and Affirmative Action employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.
Current UPHS employees must apply HERE