Director, Quality and PI

Director of Quality and PI

FT, 40 hours per week

• Develops and directs the implementation of the Quality Improvement program and Risk Management Plan. Reports QI/PI & Risk Management findings to the Board, leadership, and outside entities as necessary.
• Lead multidisciplinary teams through education and training to foster a culture of continuous improvement.
• Apply models like Lean, Six Sigma, or Plan-Do-Study-Act (PDSA) to gain efficiency and reduce errors.
• Ability to perform Root Cause Analysis to investigate adverse events, identity system failures and implement preventative solutions.
• Review and analyze current QI/PI trends and existing activities to develop and implement quality improvement initiatives to lead to better patient health outcomes.
• Oversee implementation of new processes and procedures to provide risk analysis and reduce risk to the organization.
• Coordinate and oversee the collection of data and ensure the integrity and confidentiality of data.
• Serves as the liaison for all survey activities required by HRSA, Joint Commission, CMS, ODH and any other applicable regulatory body.
• Track core clinical measures like UDS measures, HEDIS, HRSA and CMS core measures
• Direct Value Based Care to align quality metrics with reimbursement models tied to positive patient outcomes.
• Knowledgeable of national patient safety goals and incorporates them into essential functions.
• Maintains knowledge and coordinates organizational compliance efforts regarding rules, standards, and regulations.
• Directs and coordinates data for all programs to recommend and establish information systems necessary to support programs.
• Direct all activities related to patient and client rights, including oversight of Patient Advocate, reports of family/patient complaints and grievances and makes recommendations as appropriate. Maintains knowledge, laws and rules regarding patient rights program.
• Develop and implement patient safety programs. Provides and reports responses to medical or health care related errors, both internally and externally.
• Develop and implement the MHS Corporate Compliance Program, including training and education and reporting to the Board of Trustees, leadership, and outside entities as necessary.
• Follows all universal precautions for safety, infection control and follows all state, federal and joint commission health and safety standards.
• Treats patients and family with dignity and respect at all times and holds all patient information in the strictest confidence.
• Adhere to professional standards, policies and procedures, federal, state and local requirements and Joint Commission standards, including National Patient Safety Goals. Presents a positive image of MHSCC to other community agencies, caregivers and citizens
• Completes all MHS required education and training, including initial agency orientation, mandatory training and education, and upkeep of all required certifications and licensures as required by state, federal and regulatory requirements.
• Demonstrates organizational stewardship and exemplifies the mission, vision and values of MHS.
• Performs other job-related tasks as assigned

Education/Experience

• Bachelor of Nursing, Counseling, Social Work, Psychology or healthcare administration (master’s preferred) -OR-
• 5 Years’ Experience in Quality, PI or Risk Management or Healthcare Administration.
• Experience with Joint Commission, federal and state (Ohio) regulations and standards preferred.

Licensure/Certifications

• RN, LPN, LSW or related licensure preferred but not required
• NVCI
• CPR (BLS)/First Aid