Director of Patient Safety, Quality, and Regulatory Compliance

Denver Health is seeking a dynamic and talented healthcare leader to be our Director of Patient Safety, Quality, and Regulatory Compliance. The primary responsibilities of the leader in this role are to plan, implement and coordinate ongoing system-wide clinical performance improvement activities to promote patient safety and high quality of care. In collaboration with the Chief Quality Officer, the director establishes and maintains an enterprise focus on continuous improvements in the culture of safety, creates and maintains a culture of performance improvement using Lean and other tools, and provides oversight and support for a comprehensive system of adverse event reporting and response. This leader also plans, implements, and coordinates system-wide regulatory efforts to maintain compliance with Colorado State Rules, CMS Conditions of Participation, and Joint Commission Standards. We seek candidates who have strong leadership and interpersonal skills, exceptional communication and influencing skills, and the ability to perform value analyses of various strategic options to inform creative solutions to complex healthcare challenges. 

Job Summary

In collaboration with the Chief Quality Officer, plans, implements and coordinates ongoing system-wide clinical performance improvement activities to promote patient safety and quality of care at Denver Health. Plans, implements, and coordinates system-wide regulatory efforts to maintain compliance with Colorado State Rules (healthcare CSR), CMS Conditions of Participation, and Joint Commission Standards. Provides accreditation support and guidance for hospital operations related to regulatory compliance, accreditation and patient safety and quality.

 Responsibilities

• Establishes and maintains an enterprise focus on continuous improvements in culture of safety measures. • Creates and maintains a culture of performance improvement and change management using Lean and other tools. • Provides oversight and support for a comprehensive system of adverse event reporting and response. • Oversees the function of a centralized document management system (PolicyStat). • Develops process improvement plans for new patient safety and quality or mandated regulatory initiatives. Participates in departmental and organizational strategic planning. • Facilitates interdisciplinary continuous quality improvement approaches; identifies actual/potential problems; utilizes innovative problem-solving techniques; exhibits commitment to problem resolution and provides follow up. • Assists with or oversees regulatory reviews and preparation for reviews. • Designs and implements improvements in communication, monitoring, or enforcement of compliance standards. • Conducts periodic internal reviews or audits to ensure that compliance procedures are followed. • Collaborates with the CNO, Nurse Executives, and Ancillary Directors to develop and integrate the individual unit plans and strategies into overall organizational plans to achieve optimal contribution to the enterprise strategy. • Develops strategies and procedures for both obtaining and maintaining regional, specialized, and programmatic accreditations. • Ensures that all direct reports maintain current licensure, education requirements, certifications, competencies, and all other job requirements pertinent to assigned positions at all times. • Facilitates the annual preparation of the operating budget, in collaboration with the CQO, according to guidelines established by the enterprise. • Reviews, analyzes, prepares and submits regular financial, staffing, and productivity reports within the required time frame including variance reports, etc. • Ensures departmental standards and practices are consistent enterprise goals and in compliance with the Joint Commission, state, and federal accreditation regulations. • Attends formal educational classes as required by Denver Health. Pursues learning opportunities to enhance performance. • Ensures integration, coordination and communication of staff and patient education/orientation programs. • Participates with CNO and NEC to ensure that appropriate and effective manager and staff development, continuing education, and in-service/orientation programs are provided. • Remains current on all job-related knowledge, skills, and on-going education, credentialing and certification requirements. • Enhances employee engagement by providing the resources, support and tools to work in the form of extra time, brainpower and energy. • Mentors, guides and coaches direct reports in order to expand their capabilities and build management depth in the organization for succession planning. • Recruits, staffs, trains, counsels, advises, evaluates the performance of, and when necessary, disciplines and/or discharges nursing staff. • In collaboration with the CNO and CQO, reviews and/or approves employee disciplinary action including termination and ensures compliance with hospital policy; provides guidance and/or support to managers and meets with employees as indicated. • Other duties as assigned.