Description

SUMMARY:

Responsible for supporting and directing the activities of all hospital quality services in accordance with established hospital policies and procedures to provide quality health care services. Responsible for Risk Management and hospital licensure.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

May include, but is not limited to the following:

• Provides guidance and ensures system-wide performance of quality services to all departments.
• Provides guidance and ensures efficient performance in accordance with overall company and hospital goals and objectives as it relates to the quality services departments.
• Provides support, communications, and holds accountable data collection processes between corporate departments, hospital departments, and external entities.
• Serves as a system-wide resource regarding state/federal regulations/laws and Center for Improvement in Healthcare Quality (CIHQ) standards for all healthcare facilities.
• Performs Mock Surveys on all healthcare facilities periodically per schedule.
• Monitors Accreditation site for hospital compliance on items due for each healthcare facility.
• Provides survey updates on all hospitals.
• Provides support to all healthcare facilities when assistance with Plans of Corrections are required.
• Orients all new Quality Department personnel.
• Supports, directs, and holds accountable all healthcare facility quality positions (e.g. Quality, Risk Management, Infection Control, Education, Employee Health, and IRF PAI Coordinator).
• Creates, reviews, and revises clinical policies (e.g. Quality, Risk Management, Infection Control, Employee Health, Education).
• Creates, monitors, and supports corporate education, hospital orientation, education framework, and quality related education as well as completion of such education.
• Creates as needed and monitors educational modules on educational software.
• Provides support to quality areas via email, phone calls, and monthly phone conferences.
• Available via cellular phone 24 hours/day and 7 days/week for emergency or urgent issues except for Paid Time Off.
• Monitors and provides support for corporate education as well as monitoring of all healthcare facilities for completions.
• Other duties as assigned.

Job Function:

• Provide the governing framework for supporting quality patient care, treatment and services.
• Leads and directs all quality management actives for the hospital including patient care and relations, CIHQ compliance, risk management and safety, performance improvement and infection control.
• Active participation as an executive team member in strategic planning, developing processes and systems and evaluation their effectiveness to meet fiscal as well as quality outcomes. A member of the Governing Board and Medical Staff Committees.
• Creates an environment that enables a hospital to fulfill its mission and meet or exceed its goals. Collaborates with hospital and physician organization leaders to envision, develop and implement the organization’s quality and patient safety plan.
• Continually assesses the clinical care value outcomes achieved by the interdisciplinary team. Make “on the unit” rounds regularly and interact to attain clinical care value outcomes.
• Develops a long range strategic plan that reflects service design, resource allocation and organizational policies. Provides direction, staffing for care and treatment and services. Coordinates interdisciplinary clinical value care management system and assesses outcomes.
• Overseas regulatory readiness, quality measurement, public reporting and pay-for-performance programs and initiatives, holding staff and departments accountable for achieving performance goals.
• Develops, evaluates and maintains quality dashboards and performance metrics. Involved in coaching and teaching staff.
• Supports and mentor’s employees of the hospital and other staff, students, and trainees with interest in quality and patient safety.
• Maintain current competency and expertise in quality and patient safety.
• Improves safety and quality of care by implementing a safety management plan. Ensure that a process is in place to measure, assess and improve the hospital’s clinical performance. Use of clinical practice guidelines and standardized Quality/Risk policies.
• Establishes quality measurement and improvement activities, including methods to track implementation of action plans following site surveys and critical events reviews.
• Oversees reporting and communication of quality improvement initiatives, quality and patient safety awareness, safety culture survey administration and recognition programs.

Qualifications

Education

Bachelor of Science degree in a healthcare related field. Master’s degree preferred.

License/Certification

Current license in degreed healthcare related field for the state of practice. Must maintain license throughout employment.

Experience

Minimum of five (5) years of previous healthcare quality experience. Ability to work cross functionally with all levels to perform job duties. Proficient in typing and use of Microsoft Word, Outlook, Excel and PowerPoint. Exceptional communication skills, both verbal and written

SUPERVISORY RESPONSIBILITIES:

N/A

OTHER REQUIREMENTS:

Participates in or conducts company-wide sponsored training to safeguard against improper use and disclosure of patient’s protected health information. Monitors and ensures compliance with company policies, procedures, state and federal regulations and Accreditation Standards.

Company Specific

• Adheres to dress code, appearance is neat and clean and wears appropriate identification while on duty.
• Adheres to all smoking or tobacco regulations established by corporate building owners, state, or federal laws.
• Completes annual health, safety, and education requirements. Maintains professional growth and development.
• Maintains confidentiality of all patient and/or employee information to assure patient and/or employee rights are protected.
• Demonstrates knowledge of the principles of growth and development and the skills necessary to provide age appropriate care to the patient population served.
• Reports to work on time as scheduled; adheres to policies regarding notification of absence.
• Attends all mandatory in-services and staff meetings.
• Represents the organization in a positive and professional manner.
• Complies with all organizational policies regarding ethical business practices.
• Communicates the mission, ethics, and goals of the hospital, as well as the focus statement of the department.
• Maintains current licensure/certification for position, if applicable.
• Consistently demonstrates superior customer service skills to patients, physicians, visitors, employees, and any other individuals with whom they may come in contact.
• Consistently follows departmental and hospital Health, Safety, Security, Hazardous Materials policies and procedures.

• HIPAA: Conduct job responsibilities in accordance with HIPAA privacy laws, follow hospital policy in provision of patient confidentiality. Able to identify patient confidentiality issues and reports to proper hospital personnel immediately.

• Compliance: Conducts job responsibilities in accordance with standards set forth in Code of Conduct, policy and procedures, applicable federal and state laws, and applicable standards.

Core Values:

Professionalism –To always maintain the highest standard and regard for others. Keep skills, competencies and required licensures/certifications current; displays mastery over attitude and behavior and pride in appearance. Consistently performs duties to the best of abilities.

Exceptional Care—Go above and beyond expectations by providing exceptional care to WOW our customers—patients, family, physicians, and each other.

Respect – Treating others as they would like to be treated; valuing others. Acknowledges the worth of others through professional greetings, proper telephone etiquette, patience, and common courtesy.

Fun - Having fun and celebrating small successes in our journey to achieve big.  Always demonstrates a positive attitude toward work and devotion to our passion and task at hand.

Teamwork –To function as a unit, with common goals, recognizing we can achieve far more as a team than as individuals. Cooperates with co-workers while performing duties leading to everyone being able to achieve success and giving recognition where it is due.

Integrity – To always be honest and trustworthy in all our relationships. Demonstrates adherence to a strict moral or ethical code in performance of duties by always seeking to do the right thing.

Accountability -- Responsibility of our actions that influence the lives of our customers and fellow workers. Takes ownership of all aspects of duties shown through reliable, timely performance and responsibility.

Responsibility – Maintains accountability by doing what is expected or beyond; assuring the appropriate tasks and project items are completed. Takes ownership of all aspects of duties shown through reliable, timely performance and accountability.

Knowledge/Skills/Abilities:

• Ability to function independently in all aspects, including project identification, evaluation, contract negotiations, and coordination with management and internal departments.
• Ability to represent the company in a confident, persuasive and positive manner.
• Good interpersonal, verbal and written communication skills.
• Ability to work under stress and respond quickly in emergency situations.
• In-depth knowledge of operational, clinical and referral development systems.
• Ability to work effectively within a complex matrix organization.