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Sr Director of Healthcare Quality and Patient Safety

Department Description: Beth Israel Deaconess Hospital−Needham (BID−Needham) is a licensed 58-bed acute care community hospital. BID−Needham has served residents in Needham, Newton, Dedham, Dover, Medfield, Sherborn, Wellesley, Westwood and other surrounding communities for more than 100 years. The hospital has been recognized by several organizations for quality and safety, including the Gold Seal of Approval® from The Joint Commission and a first-place Accountable Care Compass Award from the Massachusetts Health & Hospital Association (MHA).
BID−Needham is part of Beth Israel Lahey Health, a new health care system that brings together academic medical centers and teaching hospitals, community and specialty hospitals, more than 4,000 physicians and 35,000 employees in a shared mission to expand access to great care and advance the science and practice of medicine through groundbreaking research and education.
BID Needham has had a direct affiliation with Beth Israel Deaconess Medical Center since 2000, facilitating the clinical integration of staff and resources in emergency medicine, hospital medicine (hospitalists), cardiology, radiology, orthopaedics, pathology, as well as many surgical services and oncology housed in the Beth Israel Deaconess Cancer Center and Surgical Pavilion.

Job Location: Needham, MA

Req ID: 41383BR

Job Summary: Under general direction of the Chief Medical Officer, the Sr. Director will lead the hospital in developing an organizational culture which embraces high reliability and a culture of safety and patient centeredness. The senior director ensures compliance with regulatory and accrediting bodies and third party payer ¿pay for performance¿ programs. The senior director also leads measurement and analysis of clinical care and programs. The senior director works with other leaders in the development of organizational goals and requisite quality improvement initiatives based on its strategic priorities. The position requires an individual with hands on experience working on performance measurement, analysis and interpretation of data as well as regulatory and accreditation requirements. The incumbent must also have a vision for patient safety and the ability to lead the staff toward changes that contribute to a culture of quality and safety throughout the hospital. The Sr. Director serves as primary liaison with MA Department of Public Health, MA Board of Registration in Medicine, Joint Commission, etc. and provides oversight and support for the Joint Commission activities. The Sr. Director will chair and/or participate in quality meetings as determined by the CMO and the Senior Director represents BID-Needham in relevant BILH committees and activities.

Essential Responsibilities:
  1. Trend selected data, compile statistics and report findings to the hospital leadership. This includes analyzing outcome criteria, identifying areas in need of improvement and recommending and collaborating on improvement processes based on current literature/best practices.
  2. Provides leadership to the Quality Care Committee, the Board level Patient Care Assessment Committee and participates in other organization committees. Provides relevant data needed to identify problems and initiate action plans.
  3. Represents BID-Needham in the BILH Quality and regulatory committees. Represents BID-Needham in relevant CRICO and other external activities.
  4. Supervise the Quality Improvement Analyst role, Quality Improvement Specialist role, the Patient Safety and Risk Management, the Infection Control Nurse Role and the Patient Advocate role as well as support staff.
  5. Review cases selected for case review by the QA Committee to ensure adherence to selected indicators.
  6. Attend and submit reports for Leadership, Medical Executive Committee, Patient Services and Nursing Executive Committee regarding quality improvement efforts.
  7. Provides leadership for continuous readiness and prepares for Joint Commission and other regulatory visits.
  8. Collaborate with all departments to monitor Quality Improvement efforts and monitor current policies and procedures to insure adherence with Joint Commission standards, and other regulatory requirements. Recommends best practices when relevant.
  9. Generate organization wide score card, provide statistics for critical measures and engages and collaborates with clinical leaders in the development of action/improvement plans.
  10. Prepare cases for presentation at the Departments Executive Committee meetings as needed.
  11. Has the responsibility to lead and support managers and directors in developing and improving operations to create optimal performance levels. Direct Reports: 4-6 Indirect Reports: 1-5

  12. Has full responsibility for planning, monitoring and managing department budget.

Required Qualifications:
  1. Master's degree in Nursing, Pharmacy or Legal required. Master's degree in Nursing preferred.
  2. License Registered Nurse required., or Registration Massachusetts Pharmacist required., or other licensed healthcare professional.
  3. 5-8 years related work experience required in quality management in healthcare, preferably in a Hospital setting and 1-3 years supervisory/management experience required
  4. Requires clear and concise communication skills, written and oral as well as demonstrated leadership and interpersonal skills.
  5. Must demonstrate extensive knowledge of business and health care systems, as well as understanding of financial systems and strong analytical and problem solving ability.
  6. Must have familiarity with use of multiple organizational quality portals (CMS, MA Health, Joint Commission, vendors, Vizient Clinical Data Base, etc.
  7. Advanced skills with Microsoft applications which may include Outlook, Word, Excel, PowerPoint or Access and other web-based applications. May produce complex documents, perform analysis and maintain databases.
  1. Decision Making: Ability to make decisions with significant, broad implications for the management and operations of a major department or multiple departments. Participates in decisions on overall strategy and direction of the organization.
  2. Problem Solving: Ability to address problems that are broad, complex and abstract, often involving Medical Center-wide issues and requiring substantial creativity, resourcefulness, staff engagement, Lean diagnostic techniques, negotiation and diplomacy to develop solutions.
  3. Independence of Action: Ability to set direction and vision for major departments or multiple departments. Establishes priorities, develops policies and allocates resources.
  4. Written Communications: Ability to communicate complex information in English effectively in writing to all levels of staff, management and external customers across functional areas.
  5. Oral Communications: Ability to verbally communicate complex concepts in English and address sensitive situations, resolve conflicts, negotiate, motivate and persuade others.
  6. Knowledge: Ability to demonstrate broad and comprehensive knowledge of theories, concepts, practices and policies with the ability to use them in complex and/or unprecedented situations across multiple functional areas.
  7. Team Work: Ability to lead and direct multiple collaborative teams for large projects or groups both internal and external to the Medical Center and across functional areas. Results have significant implications for the management and operations of the organization.
  8. Customer Service: Ability to lead operational initiatives to meet or exceed customer service standards and expectations in assigned unit(s) and/or across multiple areas in a timely and respectful manner.

Physical Nature of the Job:
Light work: Exerting up to 20 pounds of force frequently to move objects. Some elements of the job are sedentary, but the employee will be required to stand for periods of time or move through out the hospital campus
EOE Statement



As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. BILH requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more about this requirement

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