The Director of Quality Management, Infection Prevention and Medical Staff Services manages the facility quality and performance improvement (PI) programs, including outcomes analysis. Promotes performance improvement staff education and development. Ensures appropriate and timely medical staff operations and activities including appropriateness and completeness of Medical Staff Bylaws, Rules, Regulations, Policies, and Procedures. Ensures implementation and completeness of the Infection Control Program. RESPONSIBILITIES
Implements and manages quality initiatives and activities throughout the facility including PI activities:
- Performs annual quality and PI program evaluation and reporting.
- Develops, revises, and implements quality and PI plan.
- Serves as a quality resource to all departments, staff, etc.
- Maintains and coordinates quality and PI report cards, dashboard, and other reporting mechanisms.
- Serves as member of selected facility and departmental PI committees, teams. Serves as Quality Facilitator/Leader of root cause analysis teams, (RCAs), FMEAs, etc.
- Analyzes and reports quality and PI indicators to the Quality Committee, Administration, and others as indicated.
- Ensures compliance of corporate, regulatory, and accreditation requirements for quality, performance improvement, and patient safety.
- Serves as representative to selected Partnership and other quality committees, initiatives, etc.
- Coordinates quality activities with Quality Manager and other staff.
- Manages and guides physician peer review activities with the Quality Manager and Chief Medical Officer.
- Manages patient safety, national, corporate and other quality or patient safety initiatives. Leads and facilitates designated initiatives.
- Provides education to staff regarding quality and patient safety initiatives; promotes compliance and improvement.
- Responsible for facilitating clinical process performance improvement activities in accordance with accreditation, regulatory and licensing requirements. Coordinates facility-wide quality improvement (QI) programs, establishes standards of performance and provides assistance to the quality improvement teams. Encourages development of staff through quality improvement in-service education, participation in Continuous Quality Improvement (CQI) training for employees and other programs.
- Provides support for the Quality Committee and other PI and peer review committees; assists with analysis of QI data; and supports and facilitates specific PI projects as needed. Develops and implements policies, procedures and objectives and updates the Institutional Quality Improvement Plan as needed.
- Oversees compliance with TJC standards on a continuous basis throughout the acute care and ambulatory settings, maintains TJC Periodic Performance Review (PPR) database and monitors TJC survey readiness plans.
- Represents the facility as a key contact in the coordination of TJC Core Measures and CMS Quality initiatives. Maintains current working knowledge of TJC, NCAQ, CMS and other accreditation and regulatory standards applicable to hospital and physician office group practices. Maintains current accessible copies of regulatory standards as a resource for staff
Manages departmental operations:
Qualifications: POSITION QUALIFICATIONS
- Ensures appropriate, timely, and professional communications.
- Develops and reviews department policies and procedures at least annually.
- Develops, implements and reviews goals, objectives and priorities, ensuring alignment with hospital strategic plans.
- Organizes departmental activities based on priorities, goals, objectives, and needs as arise.
- Assigns and adjusts staffing to meet priorities, goals, and objectives of department while ensuring smooth operations.
- Performs department human resource activities, e.g. staffing, competencies, training and skill checklists; annual and periodic performance evaluations; staff relations, staffing adjustments, etc.
- Ensures appropriate supplies and equipment are available to perform activities.
- Prepares and monitors budgets, productivity and other operational activities.
- Develops and implements department performance improvement (PI) plan and submits reports as required.
- Obtains and implements databases and other computer software to enhance department performance.
- Creates and analyzes a variety of reports as requested or needed.
- Conducts and records monthly department meetings with staff.
- Creates a work environment to promote optimum working conditions and employee morale.
- Maintains confidentiality.
- Complies with all hospital policies and procedures, safety requirements, and emergency preparedness requirements.
- Oversees the management of and responsible for data analysis, collection and outcomes measures related to CHOIS, TMF, Core Measures, Q-Net, etc., and all elements related to the peer review process.
- Oversees the management of and responsible for processing and completeness of medical staff and allied health professional applications for appointment, reappointment, or privileges and compliance with professional requirements in accordance with Medical Staff Bylaws, Rules, and Regulations, and policies and procedures.
- Oversees the management of and responsible for implementation of the facility-wide infection prevention, detection, surveillance and improvement system that includes education, tracking and reporting, process consultation, improvement and building a system wide infection prevention culture.
Required: 5-7 years experience in strategic planning, performance improvement in an organization to include implementing quality initiatives. Healthcare experience required.
Preferred: Advanced degree in the fields mentioned above. EDUCATION
Required: Bachelor's Degree with preference given to Nursing, Quality Management or Healthcare Administration or ten years experience in healthcare quality and patient safety.
Preferred: Master's degree in healthcare, nursing, quality or business. Advanced training in Quality. LICENSE/CERTIFICATION
Required: Certified Professional in Healthcare Quality (CPHQ) EXPERIENCE:
Understanding of healthcare environment and strong project management skills are necessary for this position. Thorough knowledge of quality principles, theories and tools. Data analysis and statistical background a plus. Understanding human behavior and organizational behavior and organizational development knowledge is a plus. Excellent people skills and presentation skills are required .
A little about us:
HCA is the nation’s leading private provider of healthcare services. Comprised of locally managed facilities which include 230,000 employees at over 160 hospitals, over 120 surgery centers and 100 urgent care facilities in 20 states and the United Kingdom