JOB SUMMARY:
The Director of Quality is responsible for directing all hospital-wide Quality, Infection Control, Performance Improvement, and Risk Management activities in accordance with external regulatory agency requirements, accepted standards of care, and internal standards for patient care delivery as directed by hospital leadership, in order to enhance quality of patient care, increase efficiency and minimize risk.
Responsibilities
Performance Responsibilities:
Principal Accountabilities
• Provides oversight of implementation of the Performance Improvement Plan, the Utilization Management Plan, Infection Control and the Risk Management Program.
• Coordinates regulatory compliance activities including Joint Commission, DHS and CMS requirements.
• Analyzes and interprets data communicating trends and issues to Administration.
• Identifies events necessitating Root Cause Analysis and leads the facilitation of the RCA process.
• Directs the Patient Safety activities through the Patient Safety Committee and assists with issue resolution.
• Provides leadership to the Hospital PI Council, the Medical Staff PI Council and Joint Commission Committees.
• Provides oversight for risk management activities and operations.
• Analyzes and presents quality, and risk management reports.
• Provides education and communication related to quality, and risk management activities to all areas of the hospital. Develops educational materials as appropriate.
• Represents Facility system-wide activities involving Quality, Infection Control and Risk Management.
• Hires, supervises and evaluates managers for Quality, Infection Control and Risk Management.
• Establishment of strong relationship with the medical staff through participation at key medical staff committees. The incumbent should also demonstrate visibility, accessibility and willingness to listen to and follow up on physician concerns and suggestions.
Quality Management
• Assist with development of Performance Improvement Project in each area of responsibility. Assists in the review & analysis of results. Supports action plans developed from analysis.
• Prepares reports for Executives and the Board of Directors as needed.
Fiscal Accountability/Productivity
In collaboration with Supervisor:
• Analyzes statistics and takes appropriate action as necessary.
• Implements cost containment measures when applicable.
• Implement revenue enhancement ideas through new occupational health accounts, charge capture, and/or new services.
• Demonstrates effective time management.
Regulatory Compliance
• Monitors compliance with all applicable external agency regulations.
• Ensures compliance with all personnel to safety standards, Hazardous Materials Management program, Universal Precautions, and Infection Control.
Human Resource Management
• Demonstrates sound management and leadership principles.
• Promotes associate growth and development through effective use of resources.
• Uses effective interviewing skills to hire qualified and compassionate staff.
• Demonstrates awareness of and ability to apply knowledge of current developments in healthcare.
• Ensure Values are reflected in carrying out the duties and responsibilities of the position.
• Participate in professional organizations and activities.
Operational
• Flexes staffing based on the needs of the Medical Center.
• Maintains budget and productivity accountability.
• Implements mechanisms to maintain financial viability of areas of responsibility.
Accountability
• Maintains confidentiality of all patient and hospital related communications, documents, and records.
• Maintains clinical and management skills and expands knowledge base through participating in conferences and seminars.
• Performs required duties in accordance with prescribed hospital policies and procedures.
• Maintains an awareness of Hazardous Materials and is compliant with safety and infection control policies.
• In accordance with the mission and philosophy of the Facility, performs work consistent with the standards of Facility, the community, and regulatory agencies.
• Maintains a positive attendance record and is prompt in reporting to work.
• Assesses personal learning needs and utilizes available resources in self development including new equipment/products used in performance of job.
• Demonstrates active listening skills and treats all contacts with dignity and respect.
• Accomplishes objectives within prescribed time frames by prioritizing and organizing workload.
Qualifications
Job Requirements
Minimum Education
• A minimum of a bachelor's degree (Masters Degree in a Healthcare curriculum preferred).
Minimum Work Experience
• Must have minimum of two year's experience in an acute care hospital; one year of supervisory experience.
Required - preferred Licenses/Certifications
• CPHQ certification preferred.
Required Skills, Knowledge, and Abilities
• Must be knowledgeable regarding Joint Comission and governmental regulations.
• Must have expertise in Joint Comission survey preparation and coordination.
• Must have a high level of written, verbal and interpersonal skills.
• Proficient in basic computer skills and understanding of various operating systems. (i.e., MS Windows, Outlook, Word, Excel, PowerPoint)
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