Premier Safety Institute

Template: Job Description for Chief Quality and Safety Officer TITLE: CORPORATE VP, CHIEF QUALITY AND SAFETY OFFICER SUMMARY DESCRIPTION: Working in partnership with the __________ s !s"ste#$ %ea&ership an& #e&i'a% sta(( %ea&ership) pro*i&es %ea&ership in the &e*e%op#ent an& #eas+re#ent o( the _________ s !s"ste#$ approa'h to ,+a%it"-per(or#an'e i#pro*e#ent !PI$ an& #e&i'a% sa(et". Initiates an& o*ersees the &e*e%op#ent o( a 'o#prehensi*e ,+a%it"-per(or#an'e i#pro*e#ent progra#. In 'on/+n'tion with the #e&i'a% sta(( an& s"ste# %ea&ership) &ire'ts an& 'oor&inates ,+a%it"-per(or#an'e i#pro*e#ent initiati*es (or the __________!s"ste#$. In 'o%%a0oration with '%ini'a% sta(( an& ser*i'es 'hie(s) parti'ipates in the &e*e%op#ent) #onitoring) reporting) an& i#pro*e#ent o( a'ti*ities re%ate& to '%ini'a% pathwa"s an& g+i&e%ines. 1osters an& #aintains 'o%%a0orati*e re%ationships with e2terna% agen'ies) p+r'hasers) an& stakeho%&ers re%ate& to ,+a%it"-per(or#an'e initiati*es. Initiates) o*ersees) an& integrates a 'o#prehensi*e #e&i'a% sa(et" progra# as a 'o#ponent o( ___________!s"ste#-an&-or (a'i%it"$ ,+a%it" ser*i'es to i#pro*e the sa(et" o( patients) *isitors) an& e#p%o"ees. Re'o##en&s PI a'ti*ities re%ate& to #e&i'a% sa(et". In 'o%%a0oration with Corporate Co#p%ian'e) Risk Manage#ent) an& 3ega% A((airs) o*ersees the in*estigation an& reporting o( e*ents as re,+ire& 0" reg+%ator" agen'ies an& ser*es as a ph"si'ian 'ha#pion in PI e((orts re%ate& to #e&i'a% sa(et". Coor&inates an& o*ersees &ata 'o%%e'tion an& ana%"sis) reporting) i#pro*e#ent a'ti*ities) an& (o%%ow4+p re%ate& to #e&i'a% errors. De(ines an& 'oor&inates the ro%es o( In(e'tion Contro%-Epi&e#io%og") Sa(et" an& O''+pationa% 5ea%th Ser*i'es) Risk Manage#ent) 6+a%it" I#pro*e#ent Ser*i'es) an& others as ne'essar". 1osters an& #aintains 'o%%a0orati*e re%ationships with e2terna% agen'ies) p+r'hasers) an& stakeho%&ers re%ate& to #e&i'a% sa(et" progra#s. Re*iews an& e*a%+ates ser*i'es o( the ____________!s"ste# an& -or (a'i%it"$ that are a((e'te& 0" #e&i'a% sa(et"-reg+%ator" iss+es) i&enti(ies pro0%e#s) #akes re'o##en&ations (or i#pro*e#ent) an& #onitors ser*i'es to ens+re that sa(et"-reg+%ator" re'o##en&ations are i#p%e#ente& an& the &esire& res+%ts are o0taine&. Proa'ti*e%" e&+'ates ____________________ !s"ste# an& -or (a'i%it"$ %ea&ership an& #e&i'a% sta(( regar&ing reg+%ator" iss+es) new stat+tes-g+i&e%ines) an& #e&i'a% sa(et"-PI a'ti*ities. Reg+%ar%" 'o##+ni'ates PI an& #e&i'a% sa(et" a'ti*ities to the #e&i'a% sta(( an& engages #e&i'a% sta(( in PI a'ti*ities. Ser*es as a reso+r'e within the _______________!s"ste# an& -or (a'i%it"$ (or #e&i'a% sa(et") reg+%ator") an& PI iss+es an& parti'ipates in a'ti*ities re%ate& to a''re&itation. Chairs the ___________!s"ste# an&-or (a'i%it"$ Me&i'a% Sa(et"-6+a%it" Co+n'i% an& works with the 'o+n'i% to esta0%ish PI priorities. 3ea&s the &e*e%op#ent o(____________!s"ste# an& -or (a'i%it"$ po%i'ies an& pro'e&+res re%ate& to ,+a%it" i#pro*e#ent- #e&i'a% sa(et" an& parti'ipates as a stakeho%&er in the 'ra(ting o( ____________!s"ste# an& or (a'i%it"$ po%i'ies.

2002 Premier Safety Institute Web site www.premierinc.com/safety. Adapted with permission, Tammy Lundstrom !, !etroit edica" #enter. $ua"ity Ser%ices, !etroit, I

Premier Safety Institute

Ens+res the &e*e%op#ent o( po%i'ies an& se'+res ________!s"ste#-(a'i%it"$ appro*a%. Sets s"ste# po%i'" (or organi8ationa% str+'t+re an& 'o%%a0orates in the appro*a% o( propose& str+'t+res. De*e%ops %ong4range goa%s) ann+a% o0/e'ti*es) an& strategies (or area!s$ o( responsi0i%it". Meas+res an& re*iews s"ste# per(or#an'e. De*e%ops an&) as appropriate) seeks appro*a% o( s"ste# 0+&get. Re*iews 0+&get per(or#an'e. Pro*i&es inp+t into #a/or 'apito% e2penses re%ate& to ,+a%it" !eg) in(or#ation s"ste#s$. Monitors a'ti*ities (or an& ens+res 'o#p%ian'e with %aws) go*ern#ent reg+%ations) 9CA5O re,+ire#ents) an& _________ !s"ste#-(a'i%it"$ po%i'ies. As &ire'te&) i#p%e#ents e2terna% an& interna% a+&it re'o##en&ations. Ens+res that hospita% &epart#ents a'hie*e o0/e'ti*es (or &i*ersit" o( their s+pp%iers. MINIMUM 3E:E3 O1 EDUCATION-TRAININ;-3ICENSURE 7$ C+rrent %i'ens+re as an MD or DO in state o( _____________. <oar& 'erti(ie& in a '%ini'a% spe'ia%t" area. Masters &egree in hospita%) hea%th'are) 0+siness a&#inistration) or e,+i*a%ent &egree pre(erre&. =$ 1i*e to se*en "ears o( progressi*e%" #ore responsi0%e e2perien'e in an a'a&e#i' hea%th'are en*iron#ent) in'%+&ing e2perien'e in #anage#ent o( '%ini'a% ser*i'es %ines or regiona% operations an& e2perien'e working in per(or#an'e i#pro*e#ent-,+a%it" #anage#ent areas. S>I33S RE6UIRED 7$ Ana%"ti'a% a0i%it" to 'on'ept+a%i8e we%% in +nstr+'t+re&) &"na#i') an&-or #+%ti&is'ip%inar" en*iron#ents re,+iring ana%"sis) (oresight) int+ition) an& #at+re /+&g#ent as we%% as a thoro+gh know%e&ge o( (+n&a#enta% &o'trines) theories) prin'ip%es) an& pra'ti'es o( se*era% &is'ip%ines to (in& so%+tions to +n+s+a% or +npre'e&ente& pro0%e#s. =$ Co##+ni'ation an& interpersona% ski%%s (or (re,+ent 'onta't with interna% '+sto#ers an& e2terna% stakeho%&ers o( the_______ !s"ste#-(a'i%it"$ to pers+a&e an& negotiate in sit+ations that are 'ontro*ersia% an&-or sensiti*e an& res+%t in a+thoritati*e &e'isions. A0i%it" to e2er'ise a%#ost 'o#p%ete &is'retion in how an& what to 'o##+ni'ate. ?$ Pro/e't #anage#ent ski%%s) in'%+&ing the a0i%it" to &e(ine progra# pro/e't or pro'ess o0/e'ti*e) i&enti(" stakeho%&ers an& their interests) p%an steps) 'oor&inate an& a%%o'ate h+#an) te'hno%ogi'a%) an& (is'a% reso+r'es to a''o#p%ish goa%s an& o0/e'ti*es in a reso+r'e(+% an& ti#e%" #anner. @$ 3ea&ership ski%%s) in'%+&ing &e#onstrate& wi%%ingness to p+rs+e %ea&ership ro%es with in'reasing %e*e%s o( a''o+nta0i%it"A 'o#(ort with &e'ision4#aking responsi0i%itiesA 'oa'hing) tea'hing) an& 'o+nse%ing ski%%sA an& the a0i%it" to inspire an& 0+i%& 'on(i&en'e in others an& to (orge a%%ian'es an& garner s+pport. B$ An in4&epth know%e&ge o( reg+%ations an& g+i&e%ines (or go*erning areas o( responsi0i%it".

2002 Premier Safety Institute Web site www.premierinc.com/safety. Adapted with permission, Tammy Lundstrom !, !etroit edica" #enter. $ua"ity Ser%ices, !etroit, I

Premier Safety Institute

Template: Job Des !"pt"o# $o! C%"e$ Q&al"t' a#( Sa$et' O$$" e! * These are same elements as prior example, but formatted as a list of issues to consider for the organizations preferred format, whether system-wide (corporate) or single facility organization. TIT3E: C5IE1 6UA3ITY AND SA1ETY O11ICER 7. Initiates an& o*ersees the &e*e%op#ent o( a 'o#prehensi*e ,+a%it" i#pro*e#ent progra#A &ire'ts an& 'oor&inates in 'on/+n'tion with the #e&i'a% sta(( an& s"ste# %ea&ership) the ,+a%it" initiati*es (or the ____________!s"ste# an&-or (a'i%it"$. 1osters an& #aintains 'o%%a0orati*e re%ationships with e2terna% agen'ies re%ate& to ,+a%it" initiati*es) in'%+&ing 0+t not %i#ite& to p+r'hasers) go*ern#ent agen'ies) an& other stakeho%&ers. =. Initiates) o*ersees) an& integrates a 'o#prehensi*e #e&i'a% sa(et" progra# as an integra% 'o#ponent o( ___________!s"ste#-an&-or (a'i%it"$ ,+a%it" ser*i'esA &e(ines an& 'oor&inates the parti'ipation o( In(e'tion Contro%-Epi&e#io%og") Sa(et") O''+pationa% 5ea%th Ser*i'es) Risk Manage#ent) 6+a%it" I#pro*e#ent Ser*i'es) an& others as ne'essar". Esta0%ishes re%ationships with e2terna% agen'ies re%ate& to #e&i'a% sa(et" progra#s) in'%+&ing 0+t not %i#ite& to p+r'hasers) go*ern#ent agen'ies) an& other stakeho%&ers. ?. O*ersees a 'o#prehensi*e Me&i'a% Sa(et" Progra# in e((orts to i#pro*e the sa(et" o( patients) *isitors) an& e#p%o"ees an& #akes re'o##en&ations (or per(or#an'e i#pro*e#ent a'ti*ities re%ate& to #e&i'a% sa(et". O*ersees reporting o( e*ents as re,+ire& 0" reg+%ator" agen'ies in 'o%%a0oration with Corporate Co#p%ian'e-Risk Manage#ent-3ega% A((airs. Coor&inates an& o*ersees &ata 'o%%e'tion an& ana%"sis) reporting an& i#pro*e#ent a'ti*ities) an& (o%%ow4+p re%ate& to #e&i'a% errors. @. O*ersees per(or#an'e i#pro*e#ent !PI$ a'ti*ities in the __________!s"ste# an& -or (a'i%it"$ in 'o%%a0oration with _________ !s"ste#) i( appropriate) an&$__________ !hospita% site) i( appropriate$ ,+a%it" i#pro*e#ent sta(( an& hospita% %ea&ership. B. 3ea&s the &e*e%op#ent o( !s"ste# an& -or (a'i%it"$ po%i'ies an& pro'e&+res re%ate& to ,+a%it" i#pro*e#ent an& #e&i'a% sa(et" an& parti'ipates as a stakeho%&er in the 'ra(ting o( ______________!s"ste# an& or (a'i%it"$ po%i'ies. C. O*ersees in*estigation an& interna% reporting o( sentine% e*ents an& ser*es as ph"si'ian 'ha#pion in PI e((orts re%ate& to #e&i'a% sa(et". D. Co4'hairs the ___________!s"ste# an&-or (a'i%it"$ 6+a%it" Co+n'i% an& works with the 'o+n'i% to esta0%ish PI priorities. E. Co##+ni'ates PI an& #e&i'a% sa(et" a'ti*ities on a reg+%ar 0asis to the #e&i'a% sta(( an& engages #e&i'a% sta(( in PI a'ti*ities.

2002 Premier Safety Institute Web site www.premierinc.com/safety. Adapted with permission, Tammy Lundstrom !, !etroit edica" #enter. $ua"ity Ser%ices, !etroit, I

Premier Safety Institute

F. Re*iews an& e*a%+ates ser*i'es o( the ____________!s"ste# an& -or (a'i%it"$ that are a((e'te& 0" ,+a%it"-#e&i'a% sa(et"-reg+%ator" iss+es) i&enti(ies pro0%e#s) #akes re'o##en&ations (or i#pro*e#ent) an& #onitors ser*i'es to ens+re that sa(et"-reg+%ator" re'o##en&ations are i#p%e#ente& an& the &esire& res+%ts are o0taine&. 7G. E&+'ates ____________________ !s"ste# an& -or (a'i%it"$ responsi0%e in&i*i&+a%s) ____________ !s"ste# an& -or (a'i%it"$ %ea&ership) an& #e&i'a% sta(( regar&ing reg+%ator" iss+es) new stat+tes-g+i&e%ines) an& per(or#an'e i#pro*e#ent-#e&i'a% sa(et" a'ti*ities. 77. Ser*es as a reso+r'e within the _______________!s"ste# an& -or (a'i%it"$ (or per(or#an'e i#pro*e#ent- #e&i'a% sa(et"-reg+%ator" iss+es an& parti'ipates in a'ti*ities re%ate& to a''re&itation. 7=. In 'o%%a0oration with ______________!'%ini'a% %ea&ers) ser*i'e 'hie(s$) parti'ipates in the &e*e%op#ent) #onitoring) reporting) an& i#pro*e#ent a'ti*ities re%ate& to '%ini'a% pathwa"s an& g+i&e%ines. 7?. Sets s"ste# po%i'" (or organi8ationa% str+'t+re an& 'o%%a0orates in the appro*a% o( propose& str+'t+res. De*e%ops %ong4range goa%s) ann+a% o0/e'ti*es) an& strategies (or area!s$ o( responsi0i%it". 7@. Co%%a0orates with ___________In(or#ation Ser*i'es to &e*e%op 'o#p+teri8e& #e&i'a% re'or&s) ph"si'ian or&er entr") an& n+rsing &o'+#entation to i#pro*e #e&i'a% sa(et". 7B. De*e%ops an&) as appropriate) seeks appro*a% o( ________-s"ste# 0+&get. Re*iews 0+&get per(or#an'e. Pro*i&es inp+t into #a/or 'apito% e2penses re%ate& to ,+a%it" !eg) in(or#ation s"ste#s$.

2002 Premier Safety Institute Web site www.premierinc.com/safety. Adapted with permission, Tammy Lundstrom !, !etroit edica" #enter. $ua"ity Ser%ices, !etroit, I