DIRECTOR OF QUALITY AND QIPP PROGRAMS- FULL TIME

Position Summary:

The Director of Quality and QIPP Programs is responsible for coordinating and integrating hospital-wide quality assurance and performance improvement (PI) activities. Collects data and prepares reports relative to QA and PI activities. Assists departments and /or committees with planning, investigation and development of corrective action plans and quality assurance activities.  Attends monthly QAPI meetings at area Skilled Nursing Facilities (virtually and quarterly in person) and oversees their Quality Improvement initiatives. 

Competencies:

Communication proficiency

Ethical Conduct

Flexibility

Supervisory Responsibility:

This position does not have supervisory responsibilities.

Work Environment:

This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets, fax machines, and other equipment as needed.

Physical Demands:

The physical demands described as follows are representative of those that must be met by an employee to successfully perform the essential functions of this job.

While performing the duties of this job, the employee is regularly required to talk and hear.  Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus. Duties regularly require standing, walking, bending, kneeling, stooping, pushing, pulling and crouching as well as lifting and/or moving up to 50 lbs.

Position Type/Expected Hours of Work

This is a full-time position, and core hours of work are Monday through Friday 8 hours per day with no overtime.  Position requires work schedule flexibility based on needs of the facility.

TRAVEL

Occasional or frequent travel is expected for this position.

Required Education, Experience and License

Registered Nurse preferred

Ability to work with staff, physicians, directors and patients

Professional License as applicable or Texas Driver License if driving for SCH with an acceptable record

Preferred Experience

2 years working in a hospital setting

2 years working in healthcare Quality preferred

Responsibilities:

Develops and implements systems and policies and procedures for the identification, collection and analysis of quality and performance measurement data.

Educates and trains staff in the quality improvement plan and performance improvement program and their responsibilities.

Coordinates Quality Management Committee meetings, assist QI assistant in recording minutes.

Assists the medical, nursing and other professional staff in the developing of Quality Assurance programs, monitors indicators of care and reviews criteria. Reviews quality assurance data and refers information to the appropriate committee, department, service or individual for information, use or action as indicated and prepares reports for

Administration.

Collects and summarizes performance data, identifies opportunities for improvement, and presents findings quarterly to the Quality Management Committee and Board of Directors, Healthcare integration (HDI), CMS, Texas Safety Network (TSN) and other reporting entity.

Analyzes Press Ganey customer survey data to identify opportunities for improvement and presents findings to appropriate departments and Administration.

Participates on hospital committees as required or needed and assist in reporting in the Safety committee.

Manages the Rural Community Healthcare Network (RCHI) program and submits patient charts for review. Coordinates monthly with Medical Staff for Teleconference Peer Review.

Works with appropriate departments for submitting relevant data.

Works with Nursing Service and Medical Records to submit quality data to TMF, HDI and other data bases as required.

Assist in initiating, training and set up of new systems as needed.

Performs root cause analysis as needed for near misses and adverse events.

Attends monthly QAPI meetings at area Skilled Nursing Facilities and oversees their Quality Improvement initiatives. 

AAP/EEO Statement

Sweeny Community Hospital provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics.

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for their job. Duties, responsibilities, and activities may change at any time with or without notice.