Job description

Job Summary

The Director of Quality and Performance Improvement plans, administers, directs, coordinates and monitors all quality activities of the hospital and clinic while keeping the CEO and Board informed of its overall quality condition. The Director of Quality and Performance Improvement will be a member of the leadership team and will assist the team in setting organizational goals related to Quality and Patient care. This position is responsible for the Hospital and Clinic PI program; reporting as required to all State and Federal regulatory groups, providing communication to all staff and the board on the PI and Quality of the clinic and hospital.

Responsibilities and Duties

• Serves as a resource for Medical Staff, leadership and staff for quality improvement activities, education, and the use of quality principles and tools.
• Directs the processes of monitoring, measuring, and assessment of patient care and support of systems to achieve safe, high quality healthcare services.
• Directs and produces the hospital Performance Improvement Plan.
• Develops strategic plans for healthcare improvement in collaboration with senior leadership and clinical managers.
• Directs and manages voluntary and required quality reporting to fulfill Core Measures, HCAHPS, and other regulatory and leadership needs.
• Facilitates Quality Improvement teams and projects.
• Maintains compliance with all applicable regulations as established by the Federal and State government and other regulatory agencies.
• Oversees and directs the incident reporting system (QMM).
• Reviews and analyzes incident data and advises leadership on ways to improve processes and practices.
• Presents results of improvement efforts and ongoing performance measures of clinical processes.
• Works with malpractice insurer and attorneys to coordinate the investigation, processing and defense of hospital related claims.
• Directs activities to maximize successful surveys and inspections by State agencies.
• Educates leadership and staff in appropriate areas to minimize risk and maximize compliance with Federal and State regulations.
• Facilitates root cause analyses and failure modes effects analyses for applicable situations.
• Works closely with Performance Improvement Committee to coordinate and facilitate such meetings.
• Actively participates on the Senior Leadership team in order to achieve strategic and operational goals and objectives.
• Develops and manages departmental operating budget.

Qualifications and Skills

Bachelor's degree in Nursing, Public Health or related field with a minimum of 10 years of relevant experience is required. A Master's degree in Nursing or Public Health is preferred.

• Skill in examining and re-engineering operations and procedures, formulating policy and developing and implementing new strategies.
• Records maintenance skills.
• Ability to analyze medical records and to conduct medical/nursing research.
• Strong interpersonal and communication skills.
• Knowledge and understanding of clinical organizational structure.
• Ability to perform complex medical record reviews and to evaluate clinical data.
• Skill in interpreting information and preparing meaningful reports.
• Investigative skills pertaining to medical/legal claims.
• Ability to develop and implement legal strategies and solutions.
• Proficient in use of personal computers and software.
• Advanced knowledge and competence in quality, patient safety and regulatory compliance.
• Proficient in the use of current technology, including Microsoft Office products. Ability to learn and effectively use electronic medical records and other systems and equipment.
• Ability to develop processes to maintain accurate documentation and records.
• Ability to cultivate effective partnerships and work in collaboration with providers, other health care professionals, caregivers, and patients. Strong leadership, facilitation, delegation, and coaching skills.
• Professional and effective written and verbal communication skills. Ability to identify and employ communication strategies appropriate to the audience.
• Demonstrated leadership, communication, education, and collaboration skills.
• Ability to work independently performing a wide variety of assignments that require the use of independent judgment, problem-solving, organization, and prioritization skills.

Job Type: Full-time

Pay: $60,000.00 - $85,000.00 per year

Benefits:

• Dental insurance
• Employee assistance program
• Health insurance
• Life insurance
• Paid time off
• Retirement plan
• Vision insurance

Schedule:

• 5x8
• 8 hour shift
• Day shift
• Monday to Friday

Work Location: One location

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