Join Community 

Community Health Network was created by our neighbors, for our neighbors. Over 60 years later, “community” is still the heart of our organization. It means providing our neighbors with the best care possible, backed by state-of-the-art technology. It means getting involved in the communities we serve through volunteer opportunities and benefits initiatives. It means ensuring our dedicated caregivers can learn and grow to stay at the top of their fields and to better serve our patients. And above all, it means exceptional care, simply delivered — and we couldn’t do it without you. 

 

Make a Difference  

Responsible for coordination and successful execution of all Quality activities which include performance improvement, accreditation and regulatory compliance survey processes and infection prevention programs Performs other responsibilities as required for the effective, safe, or efficient functioning/operation of the department and organization. Collaborates and participates with network leadership and risk management as needed. Reports to the to the VP Surgical Services. 

 

Exceptional Skills and Qualifications 

Applicants for this position should be able to collaborate with others in a team setting, have excellent communication skills, and a positive attitude toward problem-solving. 
 

4 year / Bachelor's Degree BSN and Masters preferably in a healthcare related field, OR LCSW with Master's Degree and required certifications/licensures is also acceptable. (Required)  Master’s Degree (Preferred)  Certifications/Licensures: (as dictated by healthcare discipline, Licensed as a Registered Nurse (RN) with a valid license to practice in the state of Indiana as listed in the Nurse Licensure Compact (NLC) )  Certifications/Licensures: (Certified Professional Healthcare in Quality (CPHQ) to be obtained within three (3) years from hire date. (Required)  7+ years: nursing experience with a minimum of three years of progressive quality management administrative experience in a healthcare setting required. Pharmacist experience is also acceptable. Experience with accreditation and regulatory compliance survey processes preferred. (Required)   Ambulatory Surgery Center (ASC): Patient and caregiver education program development and deployment, reporting of ASC quality data and state reportable events, support of ASCs in all matters related to quality, regulatory, risk, IP, and education. Participates in the RCA advisors group representing the surgery centers. Requires experience in perioperative services, AAAHC and ISDH survey preparedness and support. Provides leadership and back up support to ASC location IP functions.  Quality Accountabilities: Responsible for and manages the assigned Quality & Infection Prevention Department activities through the development and implementation of an effective organizational structure, staff supervision, and planning.   Facilitates and coordinates performance improvement processes and provides consultative services to assist in achieving regulatory, accreditation, and organizational compliance in quality and performance improvement activities so that regulatory standards are met, and accreditation efforts are coordinated. Takes an active leadership role in accreditation activities to educate and assist with regulatory readiness. Responsible for organizing and submitting action plans and collaborating with the network regulatory director, developing the chapter leaders, and utilizing AMP software tool to analyze performance, prioritize improvements, assess organizational risk and submit reports timely.   Establishes specific quality-related goals to measure the organization's processes and outcomes.   Provides leadership, back-up and local support to the network infection prevention functions.   Develops and oversees the implementation of an effective Organization-wide Quality Management program with the Medical Staff and hospital leadership so that: Clinical and Non-clinical processes, outcomes, and satisfaction are regularly measured and benchmarked, aggregated, of analyzed and reported to assigned groups. Conclusions may be drawn, actions taken, follow-up performed, and improvements made and maintained.   Reports of the above activities are made to work groups, committees, clinical core groups, Medical Staff Sections, Medical Staff Departments, the Medical Staff Executive Committee, and the Network Board Quality of Care Committee (QoCC) as requested.   Promotes and cultivates proactive, rather than reactive, quality efforts by managing variability, ensuring strong process/procedure design and effective process management.   Supports the Network focuses on standardization to reduce variation and leads teams that identify root causes of problems rather than focusing on individuals.   Acts as a change agent to identify opportunities to improve, resolve problems and evaluate the effectiveness of change and administer programs that focus on improved outcomes of patient care.   Coordinates the use of multiple clinical decision support databases available to support value analysis, outcome analysis and change management.   Supports the organization’s safety program through an exchange of patient safety, quality and infection prevention information, input into safety education and orientation, as well as providing assistance in investigating situations which pose a possible liability to the organization.   Maintains confidentiality of sensitive patients and provider specific information.