Essential Duties and Responsibilities:

1. Ensures consistent and timely service and clinical care is performed according to guidelines by all clinical staff.
2. Supervise, train, and mentor clinical staff, to include new-hire and annual competency of staff, creation and enforcement of work schedules, and clinical skills education.
3. Continually evaluates existing clinical guidelines and revises to be in accordance with regulations, polices and procedures, and best practices.
4. Provides leadership that enhances patient access, safety, and quality with an emphasis on service.
5. Direct activities that support compliance with voluntary, mandatory and contractual reporting requirements for data acquisition, analysis, reporting and improvement.
6. Lead the integration of Quality into the fabric of the organization to achieve objectives

1. 1. Direct the Quality infrastructure.
   2. Regulate the use of privileged or confidential information.
   3. Implement processes for engagement and teamwork.
   4. Create learning opportunities to advance the organization.
   5. Communicate effectively.

7. Use performance and process improvement (PPI) project management and change management methods to support operational and clinical Quality initiatives
8. Cultivate a safe healthcare environment by promoting safe practices, nurturing a just culture and improving processes that detect, mitigate or prevent harm.

1. 1. Collaborate to analyze patient safety risks and events.
   2. Identify and report patient safety risks and events.
   3. Apply safety science principles and methods.
   4. Assess patient safety culture.

9.Direct the evaluating, monitoring and improving compliance with internal and external requirements. Lead the processes to prepare for, participate in, and follow up on R/A and certification surveys.

1. 1. Guide the organization through survey processes and findings.
   2. Facilitate continuous survey readiness activities.
   3. Operationalize processes to support standards compliance.

10. Remains knowledgeable of external forces influencing healthcare and patient care management.
11. Performs direct patient care as needed.