Detroit Medical Center - Detroit, MI
Admin Director, Quality & Patient Safety
Job Summary
Admin Director, Quality & Patient Safety
We are looking for a registered nurse to oversee the Quality departments at three of Detroit Medical Center’s facilities; Harper University Hospital, Hutzel Women’s Hospital, and Detroit Receiving Hospital. With a total of over 650 beds, you will direct hospital-wide leadership at each location and manage Quality and Patient Safety responsibilities.
You will need to have your Bachelor’s of Science in Nursing and your RN license for the state of Michigan, along with three to five years of experience in a related field, with at least three years of management experience in an acute care setting. An ideal candidate will have their Masters in a health-related field or the equivalent combination of education and experience, a CPHQ or a CPPS.
Detroit Medical Center
Detroit Medical Center’s (DMC) record of service has provided medical excellence throughout the history of the Metropolitan Detroit area.
Harper University Hospital has 370 beds and is one of the most technologically advanced hospitals in the nation with fully implemented Electronic Medical Records, 100% medication scanning and advanced robotic surgery technology.
Hutzel Women’s Hospital is Michigan’s first and only hospital for women, serving as the destination for worm’s care since 1868 and ranked on the US News & World Report “America’s Best Hospitals” list.
Detroit Receiving Hospital has 273 beds and is Michigan’s first Level 1 Trauma Center and one of the busiest and most well-equipped emergency departments. This hospital trains nearly half of the practicing emergency medicine physicians in the state.
About the town
Detroit, MI
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Leapfrog Hospital Safety Scores
Detroit Receiving Hospital & University Health Center
| Measure | The Hospital’s Score | Worst Performing Hospital | Avg. Performing Hospital | Best Performing Hospital | Data Source | Time Period Covered |
|---|---|---|---|---|---|---|
| Dangerous object left in patient’s body What’s This? | 0.162 | 0.359 | 0.02 | 0.000 | CMS | 07/01/2017 – 06/30/2019 |
| Air or gas bubble in the blood What’s This? | 0.000 | 0.036 | .0004 | 0.000 | CMS | 07/01/2017 – 06/30/2019 |
| Patient falls and injuries What’s This? | 0.486 | 1.778 | 0.42 | 0.000 | CMS | 07/01/2017 – 06/30/2019 |
| Infection in the blood What’s This? | 1.401 | 3.420 | 0.81 | 0.000 | 2021 Leapfrog Hospital Survey | 04/01/2019 – 12/31/2019 and 07/01/2020 – 9/30/2020 |
| Infection in the urinary tract What’s This? | 0.431 | 2.644 | 0.75 | 0.000 | 2021 Leapfrog Hospital Survey | 04/01/2019 – 12/31/2019 and 07/01/2020 – 9/30/2020 |
| Surgical site infection after colon surgery What’s This? | 0.465 | 2.887 | 0.80 | 0.000 | 2021 Leapfrog Hospital Survey | 04/01/2019 – 12/31/2019 and 07/01/2020 – 9/30/2020 |
| MRSA Infection What’s This? | 2.169 | 3.055 | 0.84 | 0.000 | 2021 Leapfrog Hospital Survey | 04/01/2019 – 12/31/2019 and 07/01/2020 – 9/30/2020 |
| C. diff. Infection What’s This? | 0.819 | 1.949 | 0.54 | 0.000 | 2021 Leapfrog Hospital Survey | 04/01/2019 – 12/31/2019 and 07/01/2020 – 9/30/2020 |
| Death from treatable serious complications What’s This? | 149.33 | 206.08 | 159.67 | 95.65 | CMS | 07/01/2018 – 12/31/2019 |
| Harmful Events What’s This? | 1.18 | 3.35 | 1.00 | 0.60 | CMS | 07/01/2018 – 12/31/2019 |
| Dangerous bed sores What’s This? * | 0.81 | 8.80 | 0.58 | 0.04 | CMS | 07/01/2018 – 12/31/2019 |
| Collapsed lung What’s This? * | 0.20 | 0.48 | 0.23 | 0.12 | CMS | 07/01/2018 – 12/31/2019 |
| Falls causing broken hips What’s This? * | 0.09 | 0.16 | 0.09 | 0.07 | CMS | 07/01/2018 – 12/31/2019 |
| Blood Leakage What’s This? * | 2.67 | 5.58 | 2.54 | 1.26 | CMS | 07/01/2018 – 12/31/2019 |
| Kidney injury after surgery What’s This? * | 1.40 | 3.45 | 1.42 | 0.58 | CMS | 07/01/2018 – 12/31/2019 |
| Serious breathing problem What’s This? * | 5.55 | 17.09 | 5.18 | 1.66 | CMS | 07/01/2018 – 12/31/2019 |
| Dangerous blood clot What’s This? * | 5.91 | 8.41 | 3.61 | 1.65 | CMS | 07/01/2018 – 12/31/2019 |
| Sepsis infection after surgery What’s This? * | 4.66 | 9.73 | 4.96 | 2.31 | CMS | 07/01/2018 – 12/31/2019 |
| Surgical wound splits open What’s This? * | 0.82 | 1.54 | 0.86 | 0.57 | CMS | 07/01/2018 – 12/31/2019 |
| Accidental cuts and tears What’s This? * | 1.00 | 3.97 | 1.21 | 0.37 | CMS | 07/01/2018 – 12/31/2019 |
| * This measure is a part of the Harmful Events Composite and is not used for scoring. | ||||||
Process measures include the management structures and procedures a hospital has in place to protect patients from errors, accidents, and injuries.
| Measure | The Hospital’s Score | Worst Performing Hospital | Avg. Performing Hospital | Best Performing Hospital | Data Source | Time Period Covered |
|---|---|---|---|---|---|---|
| Doctors order medications through a computer What’s This? | 100 | 5 | 85.77 | 100 | 2021 Leapfrog Hospital Survey | 2021 |
| Safe medication administration What’s This? | 100 | 5 | 83.25 | 100 | 2021 Leapfrog Hospital Survey | 2021 |
| Specially trained doctors care for ICU patients What’s This? | 100 | 5 | 62.82 | 100 | 2021 Leapfrog Hospital Survey | 2021 |
| Effective leadership to prevent errors What’s This? | 120.00 | 46.15 | 116.85 | 120.00 | 2021 Leapfrog Hospital Survey | 2021 |
| Staff work together to prevent errors What’s This? | 120.00 | 0.00 | 116.49 | 120.00 | 2021 Leapfrog Hospital Survey | 2021 |
| Enough qualified nurses What’s This? | 100.00 | 17.65 | 98.16 | 100.00 | 2021 Leapfrog Hospital Survey | 2021 |
| Handwashing What’s This? | 100 | 15 | 74.36 | 100 | 2021 Leapfrog Hospital Survey | 2021 |
| Communication with nurses What’s This? | 86 | 73 | 91.10 | 98 | CMS | 01/01/2019 – 12/31/2019 |
| Communication with doctors What’s This? | 86 | 80 | 91.00 | 98 | CMS | 01/01/2019 – 12/31/2019 |
| Responsiveness of hospital staff What’s This? | 81 | 60 | 84.38 | 94 | CMS | 01/01/2019 – 12/31/2019 |
| Communication about medicines What’s This? | 74 | 53 | 77.66 | 92 | CMS | 01/01/2019 – 12/31/2019 |
| Communication about discharge What’s This? | 81 | 67 | 86.51 | 96 | CMS | 01/01/2019 – 12/31/2019 |
Official job description
Admin Director, Quality & Patient Safety
BOUNTY DESCRIPTION
Industry: Healthcare / Health Services
Job Category: Medical / Health – Nurse Leadership
JOB DESCRIPTION
Directs hospital wide leadership in quality improvement and patient safety assessment, measurement and outcomes for assigned hospitals. Collaborates to identify quality improvement and patient safety management improvement opportunities/priorities, develop quality/ patient safety process improvement plans, and implement appropriate interventions to improve clinical/service outcomes of care and support achievement of hospital and system standards. In collaboration with risk management, directs serious safety event investigations and oversees recommendations/ follow-through. Provides leadership and education to departments regarding clinical outcomes and patient safety process/ performance measurements, monitoring and evaluation. Oversees policy, pathway, protocol, and/or guideline and development/implementation and analyzes results of their use. Identifies the need for policy development and/or revision, defines policies in collaboration with higher level management input, goals and objectives. Oversees the development, implementation and/or revision of procedures/protocols in accordance with hospital and system-wide goals and objectives. Approves procedures/protocols and/or seeks other departmental approvals as appropriate. Develops, monitors and revises functional processes in accordance with goals and objectives. Provides input into the development and revision of organizational structure for area. Approves personnel actions such as hires, fires, disciplines, etc. Ensures the timely completion of performance appraisals. Develops current to intermediate goals and measures for the department. Measures and assesses performance. As requested, assists in long-range goal development. Develops and monitors budget for area. Works with Quality and Compliance staff to ensure appropriate data and tools are available to support operating units; quality, safety and performance improvement efforts. Supports activities of local committees such as LPICC, for Joint Commission and other required data tracking and/or quality improvement activities, and other tools for improving quality of care. Collaborates with physicians and other healthcare professionals across functional teams, both locally and at a system level. Monitors activities for and ensures compliance with laws and government regulations. Responsible for DMC policies, as well as Joint Commission coordination and follow-up. As directed, implements external and internal audit recommendations. Ensures hospital departments achieve objectives for diversity of their suppliers.
Qualifications:
1. Bachelors degree in Nursing. Masters degree in a health-related field or the equivalent combination of education and/or experience preferred.
2. Licensed to practice as a Registered Nurse in the State of Michigan.
3. Certified Professional in Healthcare Quality through Healthcare Quality Certification Board (HQCB) or Certified Board for Professionals in Patient Safety(CPPS) preferred.
4. Three to five years progressively more responsible experience in a related field.
5. Three years progressively more responsible management experience in an acute care facility with at least one year of frequent involvement with senior management, physicians and outside patient care providers.
6. Experience in the use of personal computers as well as knowledge of statistical or spreadsheet software tools.
CANDIDATE DETAILS
5+ to 7 years experience
Seniority Level – Director
Management Experience Required – No
Minimum Education – Bachelor’s Degree
Willingness to Travel – Never
IDEAL CANDIDATE
Quality and Patient Safety experience in an acute care setting.
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