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 directorestablishes 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.
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.
• 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.
Knowledge, Skills & Abilities
• Strong leadership and interpersonal skills, including ability to collaborate with physician and executive leadership. • Exceptional communication and influencing skills at all levels of the organization including the current client base and prospective customers. • The ability to perform value analyses of various strategic options to inform creative solutions to complex healthcare challenges. • The ability to systematically gather information from a variety of sources, analyze information, identify implications of data, draw appropriate conclusions, generate credible solutions and evaluate the consequences of choosing each alternative. • Knowledge of accreditation standards and compliance requirements. The ability to plan, implement and monitor compliance activities throughout the organization. • Ability to promote principles of high reliability. • Ability to lead improvement, achieve and sustain results. • Must be able to work in a dynamic, rapidly changing environment and take appropriate action. • Ability to synthesize high volumes of patient safety events into actions that improve overall patient safety. • Must be able to coach, develop and inspire teams to success. Computers and Technology • Proficient in Microsoft office programs including Outlook, Word, Excel, PowerPoint and Visio. • Must be proficient at navigating the electronic health record (Epic), within 2 months of hire.
• Bachelor's Degree (Required) • Completion of a Nursing Education Program which satisfies the licensing requirements of the Colorado State Board of Nursing. Bachelor’s Degree in a clinical field; Master’s degree preferred. • Typically, eight years of directly related experience. Minimum of five years as manager of a major department.
• Registered Nurse (Required) • Active State of Colorado Nursing License or Compact License. All Certifications and Licenses required for this job must be kept current as a condition of continued employment • Active State of Colorado Nursing License or Compact License. All Certifications and Licenses required for this job must be kept current as a condition of continued employment
Internal Number: 3806
About Denver Health Hospital Authority
Take your career to the next level at Denver Health, where we offer a robust benefits package and endless opportunities for growth. Denver Health is a nationally-ranked, locally-trusted, premier healthcare institution located in the heart of Denver, Colorado.Twenty-five percent of all Denver residents, or approximately 150,000 individuals, receive their health care here. We are known as an integrated health care system that encompasses multidisciplinary academic specialties, a community health system, a level I adult trauma center, pediatric emergency and urgent care center home to Denver Public Health and many of the nation’s leaders in medicine.