Director of Quality Management

At ScionHealth, we empower our caregivers to do what they do best. We value every voice by caring deeply for every patient and each other. We show courage by running toward the challenge and we lean into new ideas by embracing curiosity and question asking. Together, we create our culture by living our values in our day-to-day interactions with our patients and teammates.

Job Summary

• Responsible for planning and implementing the performance improvement program to meet the needs of the hospital. Provides education to medical staff, hospital staff, and Governing Body. Facilitates performance improvement activities, and CQI activities throughout the hospital. Acts as resource person to administrative team, department manager’s, and medical staff. Performs clinical risk management functions. Assists department managers with preparation for medical staff committees. Oversight responsibility for all regulatory body surveys, such as, JCAHO, State Licensing Review, HCFA (CMS) Validation surveys. Maintains oversight responsibility for all performance improvement activities conducted throughout the hospital. Acts as the Facility Ethics & Compliance Officer.

Essential Functions

• Responsible for planning and implementing the performance improvement program to meet the needs of the hospital
• Facilitates performance improvement and CQI activities throughout the hospital through effective organizational skills and ongoing interaction with clinical chairpersons, nurse managers, ancillary department managers, administrative team, and Governing Body to facilitate the hospital-wide Performance Improvement program
• Maintains awareness of changes in the regulations and requirements by accrediting bodies and current methodology and practices
• Manages and operates equipment safely and correctly
• Communicates appropriately and clearly to physicians, staff, CCO and administrative team
• Uses database systems to document occurrences, medical staff review functions, committee review and actions. Compiles reports for committees and administrative team
• Oversees preparation for review by regulatory agencies, educates and assists department managers to maintain appropriate policies and procedures to fulfill requirements and regulations
• Maintains a good working relationship both within the department and with other departments.
• Consults with other departments as appropriate to collaborate in patient care and performance improvement activities
• Participates in risk management and safety activities
• Provides support and assistance to medical staff officers, committee chairpersons and Governing Body, as required
• Serves as the primary liaison to the Regional Compliance Director, acting as the main point of contact for workforce members with compliance-related questions or concerns
• Escalates compliance issues promptly to the Regional Compliance Director for review and guidance
• Meets regularly with the Regional Compliance Director to discuss compliance concerns, trends, and areas for improvement
• Prepares and submits quarterly compliance reports to facility leadership and the Regional Compliance Director for awareness, findings, and potential trends in the facility

Knowledge/Skills/Abilities/Expectations

• Excellent oral and written communication and interpersonal skills
• Basic computer skills with working knowledge of Microsoft Office, word-processing and spreadsheet software
• Knowledge of current state, federal and local laws and regulations governing employee healthcare needs
• Knowledge of accreditation standards and compliance requirements
• Ability to demonstrate critical thinking, appropriate prioritization and time management skills
• Ability to work under stress and to respond quickly in emergency situations
• Ability to spend a limited amount of time on travel required
• Must have good and regular attendance
• Must read, write and speak fluent English
• Performs other related duties as assigned

Education

• Degree in a nursing required

Licenses/Certifications

• Licensed as a Registered Nurse in the state required
• Certified Professional Healthcare Quality (CPHQ) certification preferred

Experience

• Minimum three years’ experience in Quality and/or Risk Management in a hospital setting