Area Director of Quality

Our hospitals provide high-quality care that transforms the lives of those living with disabling injuries and illnesses. We distinguish ourselves through our commitment to excellence, to our patients, to our employees, and to the communities we serve.

The Area Director of Quality provides clinical leadership for the following areas: Medical Staff Services, Regulatory Compliance, Risk Management, and Quality Management/Improvement. This position must integrate company values into daily practice.

Essential Functions

• Facilitates compliance for the Hospital related to CMS, The Joint Commission, and State/Federal regulations. Completes audits to identify ongoing compliance.
• Makes Hospital visits at least quarterly, or as needed, to assigned hospitals to perform onsite analysts of ongoing performance of quality program.
• Prepares Medical Staff, hospital and hospital staff for survey activities by regulatory and accrediting agencies. Drafts survey responses to regulatory and accreditation agencies.
• Collaborates with the medical staff regarding functions related to medical staff privileging and credentialing, performance improvement measurements, professional practice evaluation development and reviews, and aggregation by practitioners.
• Facilitates the hospital performance improvement program through the collaboration with other hospital leaders. Provides guidance regarding measurements, data collection, analysis, conclusions, and process improvement.
• Implements and manages clinical risk management functions including incident reporting, investigational follow up, grievances, root cause analysis, provides notices of potential claims, and litigation management in conjunction with senior leadership.
• Educates Medical Staff and hospital employees during initial orientation, re-orientation, and as education in area of expertise is indicated.
• Ensures submission of data to internal and external databases, as required by accreditation and regulatory agencies, is submitted timely and accurately.
• Provides an environment conducive to safety for patients, visitors, and staff.
• Assesses the risks for safety and implements appropriate precautions.
• Shares patient satisfaction data with leadership/staff monthly and coordinates improvement. Identifies opportunities for improvement and coordinates the organizational efforts to improve patient satisfaction.
• Performs other duties as assigned to support overall effectiveness of the organization.

Minimum Job Requirements
Minimum Education & Experience

• Bachelor's Degree in a biological science required
• Minimum four years clinical experience preferred
• Two years in clinical compliance role preferred
• Relevant education/experience may be substituted for one another in accordance with Hospital requirements

Required Licenses, Certifications, and/or Documentation

• Clinical licensure preferred

Required Knowledge, Skills, and Abilities

• Knowledge of current Federal, State and Joint Commission standards and hospital specific rules and regulations.
• Knowledge of current infection prevention and control processes, including CDC and OSHA standards.
• Demonstrates general computer skills including data entry, word processing, email, and records management.
• Demonstrates critical thinking skills.
• Effective organizational and time management skills.
• Effective written and verbal communication skills.
• Ability to prioritize, meet deadlines, and complete complex tasks.
• Ability to maintain quality, safety, and/or infection prevention standards.
• Ability to work independently.
• Ability to maintain proper levels of confidentiality.
• Ability to work closely and professionally with others at all levels of the organization.

Physical Requirements Over the Course of a Shift

• A significant amount of sitting.
• Lifting/exerting of up to 25 lbs.
• Sufficient manual dexterity to operate equipment and computer keyboard.
• Close vision and the ability to adjust focus.
• Ability to hear overhead pages.