Director of Quality Management

The Department Director is responsible for all quality departmental functions in support of the hospital mission, vision, and facility goals. Identifies the cost-effective systems needed to support the business of the department taking into account business trends, resource availability and changes in customers. Establishes effective working relationships with all constituencies including patients, physicians, employees and vendors. Identifies and remedies through continuous clinical outcome data and employee involvement. The Director has the responsibility and authority of planning, organizing, controlling, coordinating and evaluating the activities and functions of the Quality Management Department. This position is responsible for assisting the Vice President, Medical Staff Affairs and the Manager of Peer Review to oversee the Medical Staff Peer Review process. This position also consults with administration on Risk Management issues. Required Skills Current license as a Registered Nurse in Texas. BSN required, Master's degree preferred, CPHQ a plus. One to three years' experience in Quality/Resource Management. Relevant clinical experience and previous management experience preferred. Knowledge of hospital organizations, committees, department functions, and Performance Improvement activities. Demonstrate competent administrative, communication and leadership skills. Knowledge of Joint Commission, Medicare, and TDSHS standards a must. Basic computer knowledge. Word Perfect, Word, and Excel required. Possess the ability to make independent decisions, and handle multiple projects simultaneously. Position Responsibilities Develops and implements metrics and performance targets that assess compliance with CMS, TJC and ISDH regulations and best practices in medical management. Coordinates improvement activities for successful accrediting, licensing and certification surveys (e.g., Joint Commission, Department of Health, Centers for Medicare/Medicaid Services). Assists with audits of medical staff for compliance with policies and procedures and with regulatory and accreditation requirements. Utilizes quality assurance and quality improvement evaluation methodologies for measurement of protocol compliance and to sustain survey readiness, including ongoing preparedness reviews. Analyzes data to determine trends and resource utilization for use in optimizing compliance and to prepare reports describing individual performance. Identifies through the analysis process a summary of issues and/or policies that have the potential to negatively impact clinical outcomes and/or the delivery of quality healthcare. Assists in the education of providers in the importance of following the documentation guidelines that have been established in accordance with state, Federal regulatory and accreditation requirements. Collaborates in the implementation, monitoring and reassessment of quality improvement plans. Maintains working knowledge of CMS, TJC, ISDH and HIPAA regulation standards as pertinent to the organization. Maintains the goals and objectives of the Quality Improvement Program in line with the Hospital’s Mission and goals. Monitors cases to identify trends and emerging issues and presents to quality improvement committee. Conducts focused examination of conditions requiring correction and develop a precise definition of the problem. Coordinates with providers to communicate and ensure adherence to healthcare quality management guidelines. Assists in the development of improvement plans with department/unit managers and supervisors in response to identified deficiencies. Maintains documentation related to oversight including schedules/calendars of audits and monitoring activities and electronic and/or paper copies of audits and follow-up activities. Establishes/maintains good relationships with CEO, CFO/COO, CNO and department leaders to promote a cooperative and constructive environment for improvement. Other duties as assigned. #J-18808-Ljbffr