As a joint venture between CHI Franciscan Health and MultiCare Health System, the Alliance South Sound Health has been granted approval to build and operate a new behavioral health hospital in Tacoma, WA. Our hospital is not-for-profit with the aim to provide safe, patient-centered, evidence based and trauma-informed care in collaboration with patients, families, and communities.
The Director of Quality Improvement and Patient Safety is an inspiring leader who provides strategic, operational, and thought leadership to support Alliance Behavioral Health Hospital’s mission of providing extraordinary clinical care to its patients, serving its community of patients and referring clinicians, and engaging its staff, patients, and their families in fostering innovation, education, and discovery. The Director works collaboratively with the CMO, senior leadership, risk management, nursing, pharmacy, social services and administrative leadership to develop and implement a best-in-class hospital’s quality and safety program and to ensure regulatory compliance and accreditation. Oversees all regulatory compliance work, hospital Quality Improvement programs, including medical staff quality improvement activities, and medical staff affairs including credentialing and peer review. Educates, plans, direct and supports hospital wide performance improvement throughout the various departments, actively ensuring the organization's continuous compliance with accrediting and licensing standards. Areas of responsibility include: Quality Improvement, licensing, accreditation, infection control, employee health, Washington State Department of Health Conditions of Participation coordination and Risk Management.
DUTIES AND RESPONSIBILITIES:
1. Collaborates with hospital and physician organization leaders to envision, develop, and implement the organization’s quality and patient safety plan
2. Participates in root cause analyses and failure modes and effects analyses and debriefings
3. Coordinates closely with clinical information technology and health information management to achieve organizational goals
4. Develops, implements, and administers integrative quality programs in accordance with the most recent standards of accrediting organizations, all Federal, State and regulatory agency requirements; coordinates ongoing quality and process improvement functions
5. Develops and monitors Quality management goals and objectives that are consistent with the organization's strategic plan
6. Coordinate and analyze data for presentation to the Infection Control Committee; maintain complete records of pertinent events
7. Facilitates, develops, and implement special projects as assigned by the CMO
8. Oversees regulatory readiness, quality measurement, public reporting, and pay-for-performance programs and initiatives, holding staff and departments accountable for achieving performance goals
9. Promotes a culture of safety, high-reliability, patient and staff engagement, and performance excellence
10. Develops, evaluates, and maintains quality dashboards and performance metrics
11. Supports and mentors employees of the department and other staff, students, and trainees with interest in quality and patient safety
12. Review the admitting census and summarize data in a timely fashion in order to alert the Director to unusual patterns of infection which warrant immediate investigation
13. Use Centers for Disease Control definitions of hospital acquired infections, and keep up-to-date and accurate records of all such infections in the hospital
14. Assists Department Directors in development and implementation of operating policies and procedures which reflect quality concerns and ensures interdepartmental policies and procedures concur with one another.
15. Manages and/or leads hospital wide quality or process improvement activities utilizing standard quality improvement methodology.
16. Maintain an understanding of current guidelines from regulatory and accrediting agencies with respect to the hospital-wide infection control program
17. Assist in conducting orientation of all new hospital employees, educating them as to their role in preventing transmission of infectious agents and occupational injuries
18. Conduct annual staff education on infection control and MRSA as assigned
19. Educate patients, employees, and students affiliated with the hospital about the principles of infection control in patient care to include MRSA education program, contact isolation, prevention and decolonization
20. Respond to infection control questions and problems throughout all hospital
21. Collaborates with departments and conducts hospital wide education on appropriate quality improvement and process improvement programs.
22. Respond to requests for quality information from 3rd party organizations.
23. Develops, manages and administers the Risk Management program; develops process to collect, review, and document information pertaining to all unusual occurrences, actual and potential liability claims, and high risk areas.
24. Serve as a member of hospital and medical staff committees pertinent to Quality Management and related areas as assigned.
25. Performs miscellaneous job-related duties as assigned.
1. At least 5 years of relevant acute-care hospital experience in quality, patient safety, regulatory and accreditation, or performance improvement
2. Master’s degree required, clinical experience as social worker or RN
3. Certification with CPHQ, CPHRM, and/or CPPS preferred
4. Knowledgeable and experienced in Lean, Six Sigma, PDSA or other performance improvement methods, with record of successful improvement projects
5. Strong record of leadership, project management, collaboration
6. Demonstrated analytic and computer skills including use of statistical process control charts, with strong writing, problem solving, and communication skills
Internal Number: 001
About Alliance South Sound Health
ASSURING ACCESS, RESTORING HEALTH AND HOPE
Alliance for South Sound Health is a freestanding, two-story behavioral health hospital with 120 inpatient beds in Tacoma, WA. Our hospital will provide voluntary and involuntary admissions with a focus on general adult psychiatric care.
Choose to be...
Part of a bright beginning.
The Alliance for South Sound Health is a model for the provision of behavioral health, a unique joint venture two of the largest, longest-serving nonprofit health systems in Washington State. The Alliance represents a community solution in answer to a great community need.
Part of a vibrant community.
Tacoma offers still-affordable housing just south of Seattle—the hottest real estate market in the nation. Discover weathered brick restaurants, taprooms and coffee houses…
Breathe in salty sea air and the scent of fir trees as you enjoy 400 acres of outdoor playground at Dash Point State Park. Walk or bike to your heart’s content on the 21- mile Foothills Trail. Explore the Point Defiance Zoo and Aquarium. Take a day drive to the Pacific Ocean, Mount Rainier National Park, or the arid, sunny wine country of Eastern Washington. Living in the great Pu...get Sound will fuel your fitness and feed your soul.
Part of a team that will make an impact, for our patients and for our community.
The Alliance for South Sound Health affords the opportunity to work in a state- of-the-art environment, as you collaborate with your peers and interdisciplinary professionals to ensure the best possible care for patients and compassionate support for their families. The Alliance offers a highly competitive wage and benefits package!