Director of Patient Safety & Peer Review - Behavioral Health
Full Time
Louisville, KY 40205
Posted
Job description
Overview:
Location: 2020 Newburg Rd. Louisville, KY 40205
Shift: Full Time/Days
About Us
Peace Hospital, part of UofL Health, is a private, nonprofit behavioral health hospital. One of the largest behavioral health facilities in the nation, Peace Hospital is known for providing care for children, adolescents, and adults. It’s Kosair Charities Children’s Peace Center is the largest and most comprehensive private provider of youth inpatient behavioral health services in the country. The hospital was the nation’s first behavioral health care center to open a retail pharmacist-operated, long-acting injection clinic. The clinic was established to help people adhere to prescribed medications for behavioral health conditions, such as substance use and psychotic disorders.
Our Mission
As an academic health care system, we will transform the health of the communities we serve through compassionate, innovative, patient-centered care.
Job Summary
Experience (required and preferred):
#LI-TH1
We are Hiring at UofL Health – Peace Hospital!
Location: 2020 Newburg Rd. Louisville, KY 40205
Shift: Full Time/Days
About Us
Peace Hospital, part of UofL Health, is a private, nonprofit behavioral health hospital. One of the largest behavioral health facilities in the nation, Peace Hospital is known for providing care for children, adolescents, and adults. It’s Kosair Charities Children’s Peace Center is the largest and most comprehensive private provider of youth inpatient behavioral health services in the country. The hospital was the nation’s first behavioral health care center to open a retail pharmacist-operated, long-acting injection clinic. The clinic was established to help people adhere to prescribed medications for behavioral health conditions, such as substance use and psychotic disorders.
Our Mission
As an academic health care system, we will transform the health of the communities we serve through compassionate, innovative, patient-centered care.
Job Summary
This role will drive safety innovation through the identification and deployment of Patient Safety activities and work with an interdisciplinary team of Suburban Hospital leaders to achieve organizational goals related to Patient Safety. Provides education, ensures loop closure, prepares reports, presents outcomes and participates in organizational-wide continuous improvement projects as it relates to Performance Improvement, Peer Review and Patient Safety program.
Responsibilities:
1. Develop, operationalize, maintain, and evaluate the Patient Safety, Clinical Performance Improvement, and Peer Review Program.
2. Provides a comprehensive assessment of organizational needs to identify strategies to improve patient safety and clinical outcomes and serves as a leader in the on-going advancement of a “Just Culture” that promotes the non-punitive reporting of patient safety concerns.
3. Develops and assists others in developing action plans for process improvement and ensures follow through and loop closure on these plans.
4. Works in collaboration with the Physician Chairs, Nursing Directors, Executive Director Quality, CMO, CQO and Quality Steering Committee and any others to evaluate the effectiveness and appropriateness of care and development of policies and procedures.
5. Facilitates identification and documentation of hospital-based approved performance improvement variances and complications.
6. Serves as administrator of designated patient safety system. This will include training, managing the event database, and participating in all educational activities as required.
7. Leads the investigation of all sentinel incidents (to include performing a root cause analysis).
8. Analyzes Vizient and other program identified mortality and complications data on a regular basis to identify areas for improvement, education, and safety improvement activities.
9. Develops and coordinates of projects that will enhance the Performance Improvement, Peer Review, and Patient Safety Program.
10. Lead multi-disciplinary projects related to the hospital’s overall goal to become a 5-star Vizient organization
11. Develops ongoing physician practice evaluation triggers.
12. Generates annual report information regarding activities and prepares statistical data.
13. Participates in patient safety-related research by providing data to investigators in compliance with HIPPA and ULH IRB regulations.
14. Keeps informed of the Joint Commission requirements for triennial accreditation standards for Performance Improvement and OPPE/FPPE standards
15. Completes case reviews and analyses for contributing factors to the variance in care and/or complications including all Serious Safety Events, deaths and complications.
16. Supports the Medical Staff departments in identifying and selecting opportunities for improvement and facilitates continuous performance improvement.
17. Facilitates Medical Staff Peer Review meetings and serves as a liaison between various committees to facilitate communication and referral of cases for further physician review, and report results back to referring committee.
18. Facilitates the creation of physician-department Performance Improvement Committees and assists in preparing case reviews and projects for discussions
19. Attend safety huddle to report any safety trends found in chart review.
20. Participate in Joint Commission survey activities as a PI and Peer Review expert to support ongoing Joint Commission accreditation.
21. Performs other duties as assigned
Qualifications:
2. Provides a comprehensive assessment of organizational needs to identify strategies to improve patient safety and clinical outcomes and serves as a leader in the on-going advancement of a “Just Culture” that promotes the non-punitive reporting of patient safety concerns.
3. Develops and assists others in developing action plans for process improvement and ensures follow through and loop closure on these plans.
4. Works in collaboration with the Physician Chairs, Nursing Directors, Executive Director Quality, CMO, CQO and Quality Steering Committee and any others to evaluate the effectiveness and appropriateness of care and development of policies and procedures.
5. Facilitates identification and documentation of hospital-based approved performance improvement variances and complications.
6. Serves as administrator of designated patient safety system. This will include training, managing the event database, and participating in all educational activities as required.
7. Leads the investigation of all sentinel incidents (to include performing a root cause analysis).
8. Analyzes Vizient and other program identified mortality and complications data on a regular basis to identify areas for improvement, education, and safety improvement activities.
9. Develops and coordinates of projects that will enhance the Performance Improvement, Peer Review, and Patient Safety Program.
10. Lead multi-disciplinary projects related to the hospital’s overall goal to become a 5-star Vizient organization
11. Develops ongoing physician practice evaluation triggers.
12. Generates annual report information regarding activities and prepares statistical data.
13. Participates in patient safety-related research by providing data to investigators in compliance with HIPPA and ULH IRB regulations.
14. Keeps informed of the Joint Commission requirements for triennial accreditation standards for Performance Improvement and OPPE/FPPE standards
15. Completes case reviews and analyses for contributing factors to the variance in care and/or complications including all Serious Safety Events, deaths and complications.
16. Supports the Medical Staff departments in identifying and selecting opportunities for improvement and facilitates continuous performance improvement.
17. Facilitates Medical Staff Peer Review meetings and serves as a liaison between various committees to facilitate communication and referral of cases for further physician review, and report results back to referring committee.
18. Facilitates the creation of physician-department Performance Improvement Committees and assists in preparing case reviews and projects for discussions
19. Attend safety huddle to report any safety trends found in chart review.
20. Participate in Joint Commission survey activities as a PI and Peer Review expert to support ongoing Joint Commission accreditation.
21. Performs other duties as assigned
Education / Accreditation / Licensure (required & preferred):
- Bachelor of Science Degree in Nursing required, Master of Science in Nursing or other healthcare related master’s degree preferred. Certification in specialty preferred.
Experience (required and preferred):
- Minimum five (5) years of acute care, hospital-based clinical experience in area of intended practice
- Previous experience in academic teaching hospital preferred
#LI-TH1
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