Job Summary
Directs the department of Quality Management to develop, implement and sustain the Quality Management Process for knowledge management of all system quality indicators. The director is responsible for creating and overseeing processes to: Facilitate the identification of quality and cost indicators within the strategic direction of the system quality and cost improvement plan; Provides the critical analysis of quality and cost indicator performance, directing the quality structures and leaders to find the critical to quality variables impacting performance. Consults and facilitates the change management strategy for the improvement of quality and cost as the expert analytical and change strategist for improvement. Develop and implement the data plan in conjunction with the information Center to provide ongoing communication to all levels of the organization. Support Medical Affairs in organizing the data plans, communication processes and documentation process of the peer review process.
Responsibilities
• Directs the Quality management department activities by planning and developing goals and objectives, establishing and implementing policy and procedures for accrediting body surveys to ensure that the Quality Program meets regulatory standards, laws and the Medical Center Mission and goals. Maintain working knowledge of accrediting body standards and their interpretations as related to areas of responsibility.
• Oversee Quality Improvement (QI) activities from design, implementation, and data analysis to display, reporting, and meeting preparation, maintaining close communication with physicians and appropriate management.
• Select, train, motivate, supervise, and evaluate assigned staff to ensure maximum utilization of individual and group capabilities, while providing optimal service to internal and external customers.
• Develop and monitor annual operating and payroll budgets, to ensure the Quality Management department has the necessary funds to carry out the goals and objectives that have been established for the areas.
• Maintain current knowledge of the latest developments, advancements and trends in Quality Management via seminars, workshops, professional reading, and/or actively participating in professional organizations. Integrate this knowledge as appropriate into the position. Ensure that assigned staff receive opportunities to further their knowledge.
• Maintain positive working relationship with medical staff, management, other agencies, hospital personnel and the community to ensure the Medical Center goals are optimized and good working relationships are cultivated and retained.
• Develop and direct a program of quality review capable of meeting the needs of the Medical Center.
• Develop a system of quality review enabling the Medical Center to properly manage its patient care outcomes.
• Develop methodologies for the analysis of clinical practice pattern outcomes for the purpose of improving quality and cost where appropriate.
• Collaborate with policymaking process regarding the release of clinical quality information to accredited bodies.
• Coordinate development of clinical quality database, which will appropriately characterize the quality outcomes for clinical services within the Medical Center.
• Develop methods to track, trends and interpret variances from expected treatment and outcomes, whether due to patient/clinical condition, psychosocial and demographic factors, clinical preference or system issues. Develop a process to incorporate this information inro the performance plan of the Medical Center, medical departments, medical staff committees, and operating departments, resource management and process improvement.
• Participate in Medical Center meeting and committees, as assigned.
• Develop information support systems to warehouse data of quality data abstraction, trend reporting.
• Oversees the support function to the Medical Staff peer review proceed providing analysis of physician performance outliers, remediation, and documentation of all steps in the process.
• Provide assistance in the development and implementation of valid research tools and survey methodology. Assist with planning data collection of meaningful and valid data as indicated.
• Manages the processes to prepare summaries and reports to teams, groups, and committees as identified. Assist in writing study results, findings, conclusions and relate manuscripts. Edit data utilizing appropriate software packages. Recognize deficiencies in statistical data and take steps to validate and correct. Develop statistical analysis standards for data output to ensure high degree of accuracy.
• Seek reliable sources and maintain currency and availability of information related to healthcare statistics, comparative databases, specialty organization standards and guidelines for benchmarking. Assures competency throughout the department.
• Facilitates and participates in the continuous quality improvement activities of the institution.
Knowledge, Skills & Abilities
Patient Group Knowledge (Only applies to positions with direct patient contact)
The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment or care as defined by the department’s identified patient ages. Specifically the employee must be able to demonstrate competency in: 1) ability to obtain and interpret information in terms of patient needs; 2) knowledge of growth and development; and 3) understanding of the range of treatment needed by the patients.
Competency Statement
Must demonstrate competency through an initial orientation and ongoing competency validation to independently perform tasks and additional duties as specified in the job description and the unit/department specific competency checklist.
Common Duties and Responsibilities
(Essential duties common to all positions)
1. Maintain and document all applicable required education.
2. Demonstrate positive customer service and co-worker relations.
3. Comply with the company's attendance policy.
4. Participate in the continuous, quality improvement activities of the department and institution.
5. Perform work in a cost effective manner.
6. Perform work in accordance with all departmental pay practices and scheduling policies, including but not limited to, overtime, various shift work, and on-call situations.
7. Perform work in alignment with the overall mission and strategic plan of the organization.
8. Follow organizational and departmental policies and procedures, as applicable.
9. Perform related duties as assigned.
Education
• Master's Degree
Credentials
• Registered Nurse (Required)
Work Schedule: Days
Status: Full Time Regular 1.0
Location: Memorial-MSOB
Location of Job: US:WV:Charleston
Talent Acquisition Specialist: Anita J. Ferguson anita.ferguson@vandaliahealth.org