Job Information
Trinity Health Director of Quality, Patient Safety & Regulatory Compliance in Springfield, Massachusetts
Employment Type:
Full time
Shift:
Day Shift
Description:
Come lead our Quality & Risk Management team at Mercy Medical Center, a member of Trinity Health Of New England!
This position will also have Quality responsibilities for Johnson Memorial Hospital in Stafford Springs, CT
Position Purpose
Responsible for planning, coordinating, monitoring and assessing, the Quality Improvement and Patient Care Assessment Program. Responsible for ensuring all requirements are met for Joint Commission and other applicable federal, state, and local regulatory and /or accrediting agencies, i.e. the Board of Registration in Medicine (BORM), the Department of Public Health (DPH), Department of Mental Health (DMH) and Centers for Medicare and Medicaid Services (CMS) on an on-going basis within Mercy Medical Center (MMC) and Johnson Memorial Hospital. Researches and interprets assigned standards and issues, and assesses impact on Hospital operations. The position will also hold responsibility for continued development of the Mercy quality function including our journey to become a high-reliability organization. Responsible for overseeing and managing the Medical Staff office.
What you will do
Oversee Quality Department and associated functions; Lead Joint Commission accreditation and State licensure/renewal activities
Oversee Mercy regulatory activities including the successful management of all regulatory and quality reporting
Assist in the development and implementation of policies, procedures and objectives for quality improvement, infection control, and risk management
Participate in performance improvement activities by acting as a team member, leader, coach, or facilitator
Maintain compliance with applicable local, regional and System Office and GPO contracts. Responsible for initiating intensive investigations and root cause analysis as defined by the organizational policies and procedures
Maintain ongoing hospital wide accreditation status
Assist directors in the coordination of on-site investigations by various external reviewers i.e., DPH, DMH, Joint Commission, and BORM, as well as various Trinity Health initiatives which include Patient Satisfaction, Peer Review, Credentialing
Minimum Qualifications
Bachelor’s degree in Nursing or related healthcare field, Master's preferred
Massachusetts license in nursing preferred. Will consider 5 to 10 years of strong healthcare related experience in lieu of nursing license.
Requires a minimum of five (5) years of progressively more responsible healthcare-related experience. Minimum of three (3) years previous supervisory experience of professional clinical and support staff
Requires experience in Quality Improvement concepts and tools, Risk Management, Joint Commission, and nursing management. Certified Professional Healthcare Quality (CPHQ) required or must be obtained within two (2) years of hire in position
Demonstrated strong leadership experience that includes excellent written and verbal communication skills
Requires travel to and from the various TH Of NE sites as needed
Position Highlights and Benefits
Full time salaried 40hrs Mon-Fri with flexibility to meet the needs of the department
Ministry/Facility Information
Our Commitment to Diversity and Inclusion
Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.
Our Commitment to Diversity and Inclusion
Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.
Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.
EOE including disability/veteran