Director Clinical Effectiveness and Quality Improvement - Penn Medicine Princeton Health

Responsibilities:

• 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.

Credentials:

• 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.