Open until filled

Job Summary: The Director of Quality is responsible for the oversight and management of Clinical Education, Employee Health, Infection Prevention, Risk Management, and Quality.

Reports To: CNO

Essential Job Function

1. Ensures compliance with all applicable regulatory standards within the hospital.
2. Review, recommend new, or amended policies and procedures and ensures policies and procedures are appropriately administered.
3. Direct quality management/utilization review and ensure patient quality and safety is maintained.
4. Oversee quality improvement, accreditation, and develop the quality improvement annual plan for the hospital, which is in accordance with Federal and Colorado laws, regulations, and CMS accreditation standards.
5. Coordinates the Safety, Infection, and Quality Committee and Serve on clinical and non-clinical committees where quality and risk management expertise is beneficial.
6. Provides quality data to the Executive team as requested.
7. Budgets for hospital quality improvement and accreditation needs.
8. Works with medical staff and hospital staff in the implementation of the hospital quality and accreditation programs.
9. Oversee the organization, analysis, and management of all Risk Management and Patient Safety activities of Animas Surgical Hospital.
10. Acts as a subject matter expert, resource, internal consultant, and educator for risk management issues.
11. Identifies strategies and solutions to enhance the healthcare operations environment and initiates techniques to reduce exposures to risks.
12. Provides consultation and assistance to facility leadership, staff, and physicians on day-to-day risk management issues.
13. Participate in and support Emergency Preparedness initiatives.
14. Support Quality and Risk Management goals and objectives as well as facility-based goals which contribute to the achievement of the overall strategic objectives of the organization.
15. Performs other duties as assigned.
16. Demonstrates the spirit of the philosophy, mission, and values of the hospital through words and actions and implements them into departmental processes, programs, and the working environment.
    1. Applies the principles and values of customer service and continuous quality improvement while performing day to day activities of the position.
    2. Maintains and protects confidentiality regarding all aspects of patient care, personnel, and strategic issues. Adheres to Confidentiality Policy.
    3. Maintains positive working relationships and fosters cooperative work environment. Adheres to the hospital’s Guidelines for Appropriate Conduct in the HR Manual.
    4. Displays honesty and mutual respect when communication with peers and other departments.
    5. Follows through on problems that may compromise effective job performance by using appropriate chain of command

Minimum Requirements

Education: BSN or actively pursuing BSN or higher. Professional certification CPHRM, CPHQ, CIC or other hospital related certification preferred.

Experience: Extensive experience with CMS Conditions of Participation-interpretation, maintaining compliance, action plans, etc. as well as knowledge of core measures, infection prevention/NHSN reporting, and risk management matters.

Physical Requirements

This position requires lifting, carrying, pushing, and/or pulling up to fifty (50) pounds while administering care to patients. Stooping, kneeling and/or crouching daily in delivery of patient care. Standing and walking more than five (5) hours per day; running occasionally in responding to patient care emergencies.

Working Conditions/Environmental Exposures

Environmental hazards such as chemicals, solvents, needles, needle containers, sharps, blood, body fluids, various infectious/communicable diseases, infectious medical waste, radiation, and/or radioactive materials and/or radioactive waste, proximity to moving mechanical parts. Protective clothing/equipment may be necessary.

Salary Range $97,786-$130,000.00