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Director Lean, Quality & Accreditation - Chatham Hospital

Job ID: 11717
Location: Siler City, NC
Facility/Division: Chatham Hospital
Status: Full Time
Shift: Day Job

Did you know UNC Health has Ranked #2 Most Trusted Healthcare Brand in the U.S.? The UNC Health brand was ranked as the #4 healthcare brand in the United States overall and the #2 most trusted healthcare brand, just after Johns Hopkins and before Mass General. Join our One-Great-Team!

Job Description

Description

Become part of an inclusive organization with over 40,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve.

Summary:
The Director of Quality and Patient Safety is responsible for the overall operation of the Quality and Lean Departments. The Director is responsible for aligning performance improvement initiatives with the facility’s strategic goals, mission, vision and values. The Director also develops, implements and monitors standard processes and procedures to meet or exceed established clinical quality indicators, patient safety goals and desired operational efficiency. Will also ensure that all necessary data is reported to outside agencies in a timely and accurate manner. Demonstrates knowledge of federal, state and TJC standards and regulations affecting quality, patient safety and performance improvement. The Director will lead, facilitate and support the lean transformation initiative, ensuring lean strategies are developed to improve and re-design systems and processes critical to safe, timely, effective, equitable and patient-centered care. The Director will help support a continuous survey readiness culture by partnering with the UNC liaison. This partnership will help support the hospital to drive compliance to TJC standards. The Director will help drive continuous improvement in patient satisfaction by leading Carolina Care initiatives and promoting patient satisfaction awareness.


Responsibilities:
Independently prepares and submits annual budgets consistent with management plan, addressing statistics, personnel, supplies, and other department costs; plans ad budgets for future capital needs; monitors budget monthly reporting significant variances
Monitor individual performance of staff and completes and annual performance appraisals; maintains a positive employee relations climate
Maintains sufficient staff to perform the duties and responsibilities of department; develops new and/or improves current programs; develops and implements performance improvement programs, utilizing the principles of performance improvement; ensures all department functions are in compliance with regulatory and accreditation requirements; assesses and ensures staff competency. Participates in The Quality Center Patient Safety Organization. Reviews and updates policies in a timely manner. Create and maintains the OPPE and FPPE process to ensure credentialing compliance. Participates in the UNC System Patient Safety Council.
Facilitates accreditation process across facility; assists in selection of suitable projects to provide linkage with facility goals; assist/develop facility and departmental scorecard metrics and targets
Ensures that all data for outside reporting agencies (e.g., TJC, Hospital Compare, MBQIP, NHSN etc.) are reported in a timely and accurate manner
Acts as a Chatham liaison for Risk, Accreditation and Patient Satisfaction departments at UNC. Participates in committees, board sub-committees and task forces, including, but not limited to, Senior Leadership, MCC meetings, ASE Committee, Nursing Practice Council, UNC System Patient Experience, Environment of Care Committee and Rounding, Value Analysis Team, Med Staff Review, Med Staff Committee, Patient Safety and Clinical Quality Board Sub-Committee, Department Directors/Managers Meeting, Surgery Committee, P & T Committee, DASON Meeting, QIOC. Leads and facilitates the Patient Safety & Clinical Quality Committee, Tier 2 Huddles, A3 Team, Carolina Care Committee and Carolina Care Spotlight
Leads Carolina Care and Patient Satisfaction initiatives. Continually keeps departments informed on current patient satisfaction scores and current trends. Acts as the administrator and trains new leaders on the Press Ganey Platform. Informs leaders on upcoming survey changes. Rounds on patients to identify patient satisfaction gaps.
Leads the Patient Safety Culture Survey process and follow-up

Facilitate a steering team in the development of an organizational mission and vision that effects positive changes in patient care. Act in the capacity of role model and mentor, this individual will launch all activities needed to incorporate lean transformation into the hospital's culture; e.g., facilitate annual strategic plan generation, departmental AIMS creation, teaches and develops a variety of lean related classes (6S, CHAT Facilitator, Yellow Belt, Purple Belt, Kamishibai, VMS Leader Training, Standard Work Training, purple Belt Team Leader Training), facilitate and coach leaders and staff on lean behaviors, facilitate improvement projects, create and operate a Share Point site to establish transparency and ease of access for leaders and departments. Continuously monitor and adapt to lean culture gaps. Prepares and analyses data to identify process improvement opportunities.


Other Information

Other information:
Education Requirements:
● Bachelor's degree in a related field
Licensure/Certification Requirements:
Professional Experience Requirements:
● Requires five (5) years of health care experience and an additional two (2) years in quality improvement.
Knowledge/Skills/and Abilities Requirements:
● Prefer prior experience in performance improvement, risk management, and lean six sigma
● Prefer prior experience in Lean Manufacturing Principles or Toyota Production System (TPS)


Job Details

Legal Employer: NCHEALTH

Entity: Chatham Hospital

Organization Unit: Lean Transformation 

Work Type: Full Time

Standard Hours Per Week: 40.00

Work Schedule: Day Job

Location of Job: US:NC:Siler City

Exempt From Overtime: Exempt: Yes



This position is employed by NC Health (Rex Healthcare, Inc., d/b/a NC Health), a private, fully-owned subsidiary of UNC Heath Care System. This is not a State employed position.
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Diversity Statement

The UNC Health System and the UNC School of Medicine are committed to valuing all people throughout our organization, regardless of background, lifestyle, and culture. A diverse and inclusive work environment for staff and culturally appropriate care for our patients, are essential to fulfilling our UNC Health vision of improving the health of all North Carolinians.

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