The Chief Patient Safety and Quality Officer (CPSQO), working in partnership with Wentworth-Douglass Hospital (WDH) administrative and medical staff leadership and in collaboration with Massachusetts General Hospital (MGH) and Mass General Brigham (MGB), provides leadership in the development of a culture of safety and the measurement of the quality of care identifying opportunities and strategies for performance improvement (PI).

The CPSQO reports to the WDH Chief Physician Executive (CPE), serves as a member of the Executive Team, collaborates with executive leaders, medical staff leaders, and the Senior Vice President Quality and Safety Officer MGH, to achieve system wide quality of safety goals.

Position Purpose:

• To direct Healthcare System wide quality improvement efforts with particular regard to performance measures defined by governmental, accrediting and public reporting entities, as well as internal measures of interest.
• Continuously improve safety throughout the system by reducing the risk of patient, staff, and visitor harm.
• Promote a culture of safety throughout the system.

Primary Accountabilities: Quality Functions

• Initiates and oversees the development of a comprehensive safety/quality/performance improvement program inclusive of the analysis and trending of data related to initiatives.
• Directs system wide clinical quality improvement activities, particularly those relating to measures of interest to government programs, including but not limited to CMS, FEP, Medicaid, and other accrediting and public reporting bodies.
• In conjunction with the Medical Staff and system leadership, directs and coordinates safety/quality/ and performance improvement initiatives.
• Provides medical expertise and collaboration for all Disease Management, Quality, Pharmacy, Care Management, and Medical Review initiatives.
• In collaboration with clinical staff, department chairs, service line leaders and the CMO of Wentworth Health Partners, participates in monitoring, reporting, and improvement activities related to clinical guidelines, health care quality/safety initiatives, and accreditation and regulatory requirements.
• Supports collaborative relationships with physicians and hospital.
• Fosters and maintains collaborative relationships with WDH, MGH and MGB and with external agencies, purchasers, and stakeholders related to quality/performance initiatives.
• Collaborates with and serves as liaison to the Senior Vice President of Quality and Safety MGH.  Participates in jointly sponsored programs to drive performance improvement.
• Creates, reviews, and amends medical decision-making policies as they relate to quality and safety, and reviews and recommends criteria as appropriate.
• Provides overall direction to ensure that clinical services are provided in accordance with evidence based quality and safety standards and those established via state and federal regulations, collaborates with Senior Director of Risk and Survey Readiness to assure compliance with The Joint Commission accreditation standards, including the National Patient Safety Goals.
• Assesses entity compliance with accreditation standards and regulations related to clinical care in collaboration with entity leadership and staff.  Identifies areas of vulnerability and directs the development of strategies to enhance compliance.
• Participates in Medical Management strategic planning in evaluating utilization, quality, national and local trends, and identify interventions to optimize the utilization of resources and the delivery of high quality health care services
• Provides strategic oversight for patient safety and quality related committees with accountability for distribution of organizational communication vertically and horizontally within WDH system as appropriate.
• Assists in the development of strategic opportunities to control cost and increase quality and safety, particularly relating to the components of Value Based Purchasing
• Proactively educates leadership, physicians and staff regarding regulatory issues, new statutes/guidelines, and safety/quality/PI activities using various formats.
• Regularly communicates PI and quality/safety activities to leadership and staff.
• Works closely with other Medical Directors, Director of Ml Quality Improvement, Director of Pharmacy, Medical Directors of Physician Networks and all other departments and divisions.
• Fosters and maintains collaborative relationships Northeast Healthcare Quality Foundation and other external agencies, purchasers, and stakeholders related to quality/performance initiatives.
• Manages the departmental budget effectively and determines fiscal requirements and prepares budgetary recommendations.
• Performs staff performance evaluations establishing a development plan for each employee.  Performs other related duties incidental to the work described herein.

Responsibilities: Safety Functions

• Conducts regular Safety Team Walk Rounds.
• Provides education about Clinical Safety.
• Participates in the analysis of Culture of Safety Surveys.
• Organizes occurrence safety related reporting data according to Joint Commission Standards chapters.
• Performs annual safety risk assessment based on quality data, culture of safety data, and occurrence reports to identify areas of focus for improvement.
• Drafts annual plan for safety improvement based on risk assessment.
• Identifies safety trends or issues based on occurrence reports and other data, categorized by applicable JC Chapters (NPSG’s, Provision of Care, Med Management, Performance Improvement) that may require attention in the interim between annual risk assessment.
• Assist in implementation of plans for safety improvements.
• Provides strategic oversight of proactive and reactive patient safety activities including root cause analyses, failure mode effects analyses and Sentinel Event Alerts in regards to the facilitation of process, planning, implementation and evaluation of effectiveness of process changes.
• Review and analyze safety and quality data and assist in developing plans for improvement for presentation to Performance Improvement Committee (PIC).
• Collaborates with and serves as liaison to the Senior Vice President of Quality and Safety MGH.  Participates in jointly sponsored programs to reduce patient and workforce harm.
• In collaboration with risk management, take advantage of the offerings of CRICO RMF to ensure patient safety approaches are maintained and new opportunities explored and adopted as necessary
• Oversees Infection Prevention Program (IP)
• Director of IP directly reports to the CQSO
• The CQSO assists the Director of Infection Prevention in developing IP strategies.
• The CQSO provides support to, and oversight of, the WDH System Infection Prevention program

Qualifications - External

Required Qualifications at this Level

Education: MD/DO

Experience:                            

• A minimum of five years of direct patient care experience as a Healthcare professional. A minimum of three years in accreditation/regulatory affairs/performance improvement/patient safety in healthcare.

Certification:

• Degrees, Licensure, and/or a master’s degree in a healthcare field.

Knowledge, Skills, and Abilities:

• Knowledge of accreditation standards, health care regulations, performance improvement, patient safety and policy formulation.
• Effective organizational, oral and written communication skills, problem solving, program development, computer skills, strong leadership, and team building skills.
• Ability to work with a variety of disciplines and levels of staff across departments and the health system is required.