DIRECTOR-QUALITY MANAGEMENT-HIGHLAND COMMUNITY HOSPITAL

Job Summary: The Director of Quality Management is the program and operational leader for multiple areas, including Quality Assessment Performance Improvement, Clinical Outcomes, and Patient Safety; Social Support and Post-Acute Services; Risk Management, Patient Advocacy, and Safety. The director works under the guidance of the Director of Nursing (DON) and maintains a close cooperative relationship with the organization's administrative and clinical leaders. The Director must maintain clinical skills and certifications to utilize as needed or directed.

Director of Quality Management - Ensures that processes needed for the quality management system are established, implemented, and maintained. Ensures that awareness of customer and regulatory requirements is promoted throughout the organization. Responsible and accountable for coordinating, developing, and implementing initiatives that promote transparency and awareness of outcomes. Responsible for the Environment of Care rounds for all departments quarterly. Reports to the DON on the performance of the quality management system and any need for improvement. Employs organization strategies in a balanced approach that produces meaningful contributions to each element of the facility's goals. Requires the promotion and adherence to the organization's established Compliance Program and Standards for Conduct. Responsible for the overall management and implementation of all departmental functions. Initiates activities and provides leadership to facilitate achieving the organization's goals and objectives related to quality assessment and performance improvement. Responsible for reporting data to the facility, health system, state and federal entities.,

• Social Services, Case Management and Swing Bed Coordinators - directs all care management activities, ensures patient care coordination and adherence to all facility policies, protocols, and regulatory standards. Supervise a multidisciplinary team responsible for patient discharge planning, swing bed referrals, admissions, and reporting. Ability to perform social work, case management, and swing bed coordinator duties.
• Risk Management, Patient Advocacy, and Grievances-Ensure the investigation, resolution, documentation, and reporting of organization-specific patient and visitor compliments and concerns to leadership and staff. Ensure communication related to all grievances is logged and follow-up is communicated and documented. Develop, implement, and participate in customer service and patient relations initiatives related to the facility policy. Ability to perform risk manager, patient advocate, and grievances coordinator duties.
• Quality Assessment-Performance Improvement, Clinical Outcomes, and Patient Safety -

Coordinate performance measurement and improvement among all departments, including patient

safety. Reviews and analyzes clinical information about key aspects of patient care and collaborates with directors and providers to improve patient care, safety, and service. Develops plans to improve patient safety utilizing current industry best practices. Improve clinical outcomes and patient care related to patient safety. Develop and implement accreditation and licensure compliance strategies. Serves as the Quality Assessment Performance Improvement Committee chair. Responsible for overseeing and reporting all quality measures, outcomes, reporting, and analyses for internal and external requirements such as AHRQ, CMS, and other contractual requirements. Responsible for accurate and timely submission of key data reporting to outside entities identified for this position, coordinating data needs and support with IT and Finance departments as needed. Ability to perform the Clinical Outcomes

Coordinator and Patient Safety.vs Coordinator duties.

• Policies, Protocols, and Procedures - Ensures the database is maintained, reviewed, and updated

according to schedule. Ensures the updated policies, protocols, and procedures are presented at Medical Executive committee meetings for final approval and the most up-to-date policy is available for staff.

Serves as the Policy Committee chair.

General - Employs organizational strategies in a balanced approach that produces meaningful contributions to each element of the Organizational Goals and Priorities. Requires promoting and adhering to the organization's established Compliance Program and Standards of Conduct. Demonstrates knowledge and skills to appropriately communicate and interact with patients, families, and visitors of all ages while being sensitive to their cultural and religious beliefs. Incorporates the knowledge and skills necessary to provide care appropriate to the age of the patients served; also demonstrates understanding of the principles of growth and development and possesses the ability to assess data reflective of the patient's status and interprets the appropriate information needed to identify each patient's requirements relative to his/her age specific needs, and to provide the care needed as described in the department's policies and procedures. Recruits and maintains adequate, quality staff. Supervises and directs staff. Sets and reviews job descriptions and expectations with staff.

Evaluates staff job performance. Responsible for the operating budget. Maintains all department and hospital records and enters accurate information into the electronic health record.

Performance Expectations:

• Key member of the leadership team-requires demonstrating leadership qualities through collegial relationships with other management team members and providing collaborative leadership.
• Ability to effectively communicate with departmental leaders, patients, physicians, and other members of the organization's administrative and management team in a manner consistent with a customer service focus and application of positive language principles.
• Demonstrates sound judgment in interactions with employees, physicians, and the interprofessional care team.
• Demonstrates ability to analyze performance improvement data and identify regulatory standards and requirements.
• Foster a positive work environment among staff and the hospital's administrative team.
• Collaborates with staff by actively communicating and providing comprehensive reports of pertinent information.
• Exhibits open and professional communication abilities.
• Performs duties required within the department to continue to maximum functionality during staffing crunches or emergencies

• Participates in the development of quality measurements and performance improvement plans
• Ensures that all areas operate efficiently and meet accreditation body requirements.
• Utilizes critical thinking skills, decisive judgment, and the ability to work in a fast-paced environment
• Exemplifies the knowledge and understanding of Hospital Value-Based Purchasing performance measures.
• Ensures compliance with national accreditation/certification standards.
• Exhibits the ability to promote quality achievement and performance improvement across the organization.
• Embraces and practices the We C.A.R.E. philosophy in all aspects of patient, visitor, coworker, and staff care
• Works with other departments within Highland Community Hospital and other outside agencies to provide and coordinate services that meet the clinical, financial, and patient experience goals
• Is competent to access and utilize the EMR for the provision of patient care
• Demonstrates promotion and adherence to the organization's established Compliance Program and Standard of Conduct and regulatory standards
• Responsible for adhering to budgetary guidelines and staffing productivity
• Oversees the Patient Advocate/Complaint and Grievance Coordinator. The Grievance Coordinator receives notices of grievances from individuals filing them and any additional correspondence following the initial notice. The grievance coordinator provides a written response to all notices.
• Ensures compliance with State and Federal Laws, accreditation, and professional and regulatory standards, including quality assurance and licensure requirements, policies, procedures, and moral and ethical codes.
• Monitoring activities to ensure compliance with core quality measures.
• Maintains and applies current knowledge regarding applicable regulatory standards related to safe patient care.
• Actively participates in monitoring/corrective action processes to meet respective targets and provides feedback on findings.
• Evaluate capital requests against revenue statistics.
• Collaborates with hospital administration in policy formation, program, and capital planning.\
• Leads the development of appropriate policies, procedures, and quality targets to ensure effective and efficient service, high-quality patient care, and compliance with hospital standards, external licensing, accreditation, and regulatory bodies.

This job description is not intended to be all-inclusive; the employee will also perform other reasonably related job duties as assigned.

Qualifications:

Education/Skills

Graduate of a recognized RN program; a Bachelor's degree in nursing is preferred.

Work Experience:

Requires a minimum of three years' experience and proven performance in health care leadership or performance improvement. Possession of strong communication, management, fiscal, and organizational abilities must be apparent. Prior experience in a hospital environment. Requires a strong familiarity with history, present status, and trends in quality management and performance

improvement, risk management, health financing and marketing, business sector initiatives, governmental policies, and hospital strategies.

Certification/Licensure- DUE UPON HIRE

• • Current License with the MS State Board of Nursing

Additional Certification/Licensure - Obtained based on required timeframe below

• • Basic Life Support

Within 30 Days of Employment Required

• • Advanced Cardiac Life Support Within 90 Days of Employment Required

• • Pediatric Advance Life Support Within 90 Days of .Employment Required

• • NIH Stroke Scale

Within 90 Days of Employment Required

Mental Demands:

Ability to manage conflict and change, cooperate with others, prioritize multiple tasks, exhibit leadership, demonstrate initiative, and manage the performance of others.