Director Quality, Clinical Safety & Infection Control

Responsible for directing performance improvement, and clinical safety. Provide leadership and support for the development, implementation, and evaluation of quality improvement initiatives in conjunction with the Administrative team. Direct and manage accreditation, regulation and licensing activities.

Essential Duties and Responsibilities:

Position Specific — 

• Provides consultation and guidance to the organization and medical staff in the design, monitoring and evaluation of performance improvement activities.
• Directs peer review activities in collaboration with physician advisor
• Works closely with Medical Director of Quality
• Recommends appropriate Process Improvement team formation to the Quality Management and Safety Committee
• Acts as facilitator for Process Improvement Teams
• Directs the clinical safety program including risk identification, case review, and hospital-wide quality review reporting system\
• Collaborates with Claims Management on Quality or Clinical Safety issues.
• Provides input at the highest level of Nursing Administration regarding the impact of decisions on the quality of services provided
• Serves as an appointed member of the Nursing Leadership Committee as resource and consultant
• Oversees and participates in medical record review
• Develops and revises organizational policies to assure compliance with current health care law and risk-related issues for Administrative/Board approval.
• Directs, coordinates and conducts interdisciplinary intense analysis activities/meetings to establish risk reduction strategies and action plans
• Works collaboratively with Nursing Directors to promote standards of nursing practice
• Directs the integration of infection control into performance improvement activities
• Directs CQI functions of facility to meet Joint Commission, State and Federal requirements for hospital and Medical Staff
• Directs survey preparation activities including coordinating mock surveys and organization assessment activities identifying areas requiring improvement
• Plans, develops and conducts accreditation and regulation education and orientation activities
• Coordinates accrediting and regulatory agency surveys
• Coordinates development of written response reports to regulatory and accrediting bodies such as CMS , DHS and Joint Commission.
• Provides education regarding current Quality Management regulations for Joint Commission, CMS , Department of Public Health, and insurance providers with employees and Medical Staff
• Provides reports on quality activities to the appropriate departments, including the Board of Directors
• Protects patient confidentiality
• Conforms with Affirmative Action guidelines

Leadership and Management —

• Develops and implements departmental goals and objectives with input from staff members
• Develops and implements departmental policies and procedures that guide and support the provision of services
• Interacts with all customers to ensure prompt and accurate communication as needed to provide the service expected and to meet the goals of the service
• Evaluates problems, and develops and implements solutions
• Develops new ideas and/or systems with innovation and creativity
• Challenges the status quo in looking for more efficient practices
• Leads by example and serves as a professional role model
• Updates employees on present as well as future changes
• Actively listens and tries to understand before responding
• Shapes an environment that is psychologically safe, encouraging, and non­judgmental
• Supports, encourages, and contributes to the professional growth of all department employees
• Understands, teaches and implements elements of empowerment and team building
• Responsible for the maintenance of quality control programs as appropriate
• Responsible for the continuous assessment and improvement of the quality of care and services provided
• Adheres to all Compliance & Integrity Program rules and requirements
• Attends and completes Compliance & Integrity training

Human Resources Management —

• Conforms with Equal Employment Opportunity Commission guidelines
• Recognizes, appreciates and capitalizes upon the differences people bring to the job
• Sees diversity as an advantage
• Selects staff who possess and demonstrate the required competencies and values and maintain the Customer Service Expectation and Standards of the hospital
• Develops and implements job descriptions and performance standards
• Evaluates staff performance per established policy, including the use of staff competence and quality improvement data
• Mediates personnel problems and resolves complaints using good problem solving techniques
• Demonstrates knowledge of and competently interprets and administers Hospital policies and procedures
• Conforms to the hospital Wage and Salary Administration and Recording of Hours Worked policies
• Ensures that staff is in compliance with licensure and other annually mandated requirements
• Demonstrates knowledge, interpretation and application of the terms and conditions of collective bargaining agreements

Financial Resources Management —

• Develops and recommends department operating and capital budgets
• Ensures that department operates within established budget
• Prepares and manages FTE budget, including developing staffing plans and managing monthly and daily staff schedules
• Accountable for unit productivity
• Develops and utilizes the budget as a planning and control tool
• Develops departmental strategic objectives and new programs

Information Systems Management —

• Understands departmental information systems and other equipment as necessary
• Understands advanced aspects of various information systems
• Understands and conforms to the hospital Information Technology Solutions Group strategic plan

Competence —

• Maintains an appropriate level of professional competence by ongoing development of knowledge and skills
• Performs professional duties in accordance with relevant laws, regulations and technical standards
• Prepares complete, clear reports and recommendation after appropriate analyses of relevant and reliable information

Confidentiality —

• Refrains from disclosing confidential information acquired in the course of work, except when authorized and unless legally obligated to do so
• Informs subordinates, as appropriate, regarding the confidentiality of information acquired in the course of their work and monitors their activities to assure the maintenance of confidential information
• Refrains from using or appearing to use confidential information acquired in the course of work for unethical or illegal advantage either personally or through third parties
• Follows Administrative policies on Confidentiality and Privacy Practices

Integrity —

• Regularly demonstrates commitment to a set of ethics and values by behaving in an ethical manner that is consistent with the hospital's mission, vision and values
• Avoids actual or apparent conflicts of interest and advises all appropriate parties of any potential conflict
• Refrains from engaging in any activity that would prejudice the ability to carry out one's duties in an ethical manner
• Refuses any gift, favor, or hospitality that would influence or would appear to influence one's actions
• Recognizes and communicates professional limitations or other constraints that would preclude responsible judgment or successful performance of an activity
• Communicates unfavorable as well as favorable information and professional judgment or opinions in a professional manner
• Fully discloses relevant information that could reasonably be expected to influence intended users' understanding of any reports, comments, and/or recommendations presented

Non-Essential Duties: Other duties as assigned

Knowledge, Skills and Abilities:

• Proficiency in the scientific method
• Currency in accreditation requirements and processes
• Computer literacy
• Critical thinking and problem solving abilities
• Strong influence/persuasion skills
• Assertiveness
• Ability to organize information, people and resources
• Ability to work collaboratively with and through others
• Strong writing skills
• Strong presentation skills
• Team building skills

Requirements

Education and Experience:

• MSN or MS in related field; condition of employment to complete within two years
• Basic experience or training in statistical methodologies and data analysis
• Minimum of seven years of experience in the field or in related area.

Required Licensure and/or Certifications:

• QI Certificate and/or equivalent courses
• CPR
• Maintains competency through appropriate education and training as demonstrated by the following:
• Certified Professional of Healthcare Quality Certificate (CPHQ); or qualified to take exam within two years

Benefits

This is a direct hire opportunity with our client. Full benefits will be offered.

Royalty Medical Solutions is committed to providing an inclusive and welcoming environment for all members of our community and ensuring that no person is excluded from participation in or denied the benefits of our services on the basis of race, color, religion, sex, national origin, age, disability, genetic information, sexual orientation, gender identity, or any other characteristic protected by applicable law. We prohibit discrimination in all its forms and are dedicated to promoting diversity, equity, and inclusion.