Position Description 

Conducts oversight and management of hospital compliance with external regulatory standards as defined by CMS (Conditions of Participation), DNV, state and local regulations. Supports the structure for the internal audit process, ensuring policies and procedures are compliant with standards. Monitor DNV regulatory non-conformities, preparing and relaying updates on quality and compliance. Assist the Director in maintaining awareness of licensing and regulatory matters, identify changes to regulations and accreditation standards and maintain survey readiness plan. Responsible for Leapfrog survey process. Facilitates improvement teams as needed. Specializes in current concepts of performance improvement and regulatory agency requirements; develops criteria and utilizes data analysis techniques and applications. This position requires coordination and confidential communication of critical thinking skills as it pertains to various, selected quality reviews.

Education & Experience: • 

Bachelor's degree required in Business or Healthcare Administration, Nursing or related field. • Master s Degree preferred. • 3 years of experience in an acute hospital setting with a working knowledge of data analysis and healthcare processes. • Auditor experience required. • Experience with MS Office applications required.

Knowledge & Skills: • 

Excellent verbal and written communication abilities, including strong interpersonal skills as well as organizational, analytical, and project management skills. • Self-motivated with solid knowledge of quality improvement methods and data collection/analysis. • Knowledgeable of NIAHO standards and ISO 9001 Quality Management System. • Demonstrates critical thinking skills, process design, collaboration, teamwork and able to solve problems to achieve goals. • Proficient with Microsoft Word, PowerPoint, Excel and Access for word processing, presentations, spreadsheets, and database management. • Knowledge of current concepts of quality improvement preferred.

Consultant for Inspira Quality/Patient Safety Process: • 

Knowledgeable in High Reliability, Performance Improvement (PI) and Patient Safety Process. • Provides ongoing education to all departments regarding regulatory and accreditation process for system and departments. • Facilitates process improvement efforts and outcome measurement; Mentors and develops skills of others to better lead improvement efforts and develop and improve departmental/ multidisciplinary processes. • Provides oversight and guidance to process improvement teams (sets goals, establishes agendas, manages meetings) • Works with departments to identify appropriate improvement projects; Presents project to Quality & Patient Safety Department for approval process

Continuously assesses and improves department's performance: •

 Adopts a structured approach to performance improvement; ensures that important processes and activities are measured, assessed and improved systematically using accepted performance improvement techniques (e.g., DMAIC). • 

Participates in interdisciplinary, interdepartmental performance improvement activities.

 • Ensures efficient use of time to complete assigned duties and keeps supervisor informed of progress to meet reporting deadlines. 

• Forwards relevant information to leaders including performance improvement activities and required reports in a timely fashion

. • Assigns in writing responsibilities for acting on recommendations generated throughout performance improvement activities

. • Assesses potential and actual problem/situations with consumers, staff, physicians, and other agencies, considers alternatives, selects appropriate course of action and reviews results. Recommends space and other resources needed by department:

 • Controls expenses to maximize cost effectiveness. 

• Ensures sufficient resources to support department activities.

 • Evaluates and recommends modification of existing department equipment or purchase of new equipment to best meet department needs. Understands, Supports and Reflects the Organization's Mission and Values in Day-To-Day Activities: 

• Demonstrates accountability for achieving goals. 

• Promotes open, honest communication within the department and with other departments. • Promotes and encourages free expression and acceptance of alternative opinions.

 • Encourages an atmosphere of empowerment within department. • Serves as a role model, mentor, and resource for staff, students and interdisciplinary team members.

 • Independently coaches and counsels nursing staff to improve performance.