Director of Quality

Responsible for developing, implementing and monitoring a quality review program including quality improvement and outcome management.  Infection Control, Risk Management, and Patient Safety service departments report to this position.

 ESSENTIAL FUNCTIONS:

1. Maintains knowledge of all current requirements for approved accreditation agency standards/CMA, Title 22, state and federal licensing, and other legal hospital mandates or standards required of hospital operations.
2. Develops and/or supports programs and activities to assure standards are applied to hospital-wide activities in an on-going manner, appropriate to the preparation for successful survey outcome with accreditation agencies and other organizations conducting announced or unannounced surveys.
3. Participates in organizational Performance Improvement planning, collection and reporting of data as required by Performance Improvement Plan, to meet regulatory requirements and as directed.
4. Assures programs for hospital-wide Performance Improvement/Quality Assurance programs are administered within accreditation agency standards, hospital administration.  Program shall provide monthly, quarterly, or annual comparative data to identify opportunities for improvement or change.
5. Manages department personnel including selection, hiring, evaluation, scheduling, discipline, reward processes in accordance with hospital personnel policies. Assures evaluations are timely.  Establishes personnel goals in order to meet department objectives and mission.
6. Develops departmental budget and assures parameters are met for assigned services within established expense per unit of service.
7. Demonstrates commitment to continued professional growth and development pursuing formal and informal education.

OTHER RESPONSIBILITIES:

1. Other duties as assigned from time to time.

SUPERVISORY RESPONSIBILITIES: Supervises Quality Management and Infection Control Staff

    EDUCATION, KNOWLEDGE, SKILLS, ABILITIES, AND EXPERIENCE:

1. A relevant Bachelor’s degree or equivalent is necessary.
2. Minimum 5 years acute care hospital background, with 5 years management experience and at least three years in supervisory position in two of the following areas

1. Continuous Quality Improvement, Quality Management, or Risk Management.

 LICENSES AND CERTIFICATIONS REQUIRED: None.