Director of Quality and Compliance

The Quality CCoordinatoronsultantis responsible for providing a broad range of administrative, facilitation and technical support functions, specifically in the area of Quality Improvement,and Regulatory Accreditation Readiness surveys andService and safety initiatives. Under minimal supervision, develops implements and monitors the Quality and DNV survey readiness programsorganizational quality and. Ddevelops and monitors performance indicators/metrics for organization wide performance improvement. Quality indicators. Collaborates with appropriate departments to collect, analyze and trend data from multiple reporting systems/sources to identify opportunities to improve organizational efficiency, patient safety, satisfactionand, decrease clinical riskand improve outcomes..Develops and coordinates workgroups and to address priority issues identified. Acts as a resource throughout the organization for issues related to patient safety, service, process and system optimization and clinical outcomes. Supports the various committees coordinated or chaired by the department, e.g. Service, Quality Resource ManagementOversight, Safety System Oversight Committee, and the Continuing Care Quality Oversight Workgroup. Ensures organization's compliance with accreditation and licensing standards, laws and regulations, and internal requirements related to quality and patient safety.

Preferred Qualifications:

Licensed clinician with Master's degree in business or health related field preferredor equivalent experience. in public health, analytics, Healthcare Administration, Business administration or a related field preferred. Healthcare Quality (CPHQ), Patient Safety (CPPS) or Risk Management (CPHRM) certificationsor ability and experience to obtain desired.preferred.

Minimal Qualifications:

Education: Graduate of a Bachelor’s Degree program in a clinical discipline or healthcare-related or managerial operationsfield orMaster’s degree in Nursing with a minimum of five (5) years’ experience in an acute care setting with demonstratedprimaryresponsibility for oversight of QualityAnalysis, service, safetyand/or accreditation surveyreadiness.

Experience:

A minimum of 5 years’ experience working within an acute care hospital to include a thorough knowledge of the clinical operations of a hospital. Prior experience in organization-wide preparation and survey readiness activities. Knowledge of the organization’s policies and procedures as well as related documents in accordance with regulatory standards.

Demonstrates excellent organizational skills and a proven ability to lead and coordinate projects.; facilitate committees; analyze interpretand present quality date and lead change.
Competent in the analysis, interpretation, explanation and presentation of performance data.
Proven ability to use appropriate verbal, nonverbal, and written communication skills for audiences at all levels of the organization.

Demonstrates the ability to work collaboratively with leaders, practitioners, and health system staff in achieving accomplishmentsoutcomes and targets set by administration.

Working knowledge of regulatory agenciesy(DNV, Joint Commission), State, and Federal regulationsquirementsregarding healthcare operations.

1. Support and participate in quality committees coordinated/facilitated by the department, including Service Quality Resources Management, Safety Systems Steering Committee, Continuing Care Quality Oversight and/or Peer Review Committees and analysis of near misses via root cause analysis.

2. Ability to collect, analyze, interpret, and presententerdata to a wide variety of audiences.into a database in order to collect information for analysis With facilitation of discussion, consensus building and development of actionabletimelines to drive organizational success..

1. Proven ability to analyze clinical/utilization/satisfaction data, organize data into understandable graphic displays, produce reports with committee/work group discussion and develop action plans to improve processes.

3. Proficient utilization of Microsoft applications: Work, Excel, PowerPoint to support analysis and display of data for continuous quality improvement.

Minimal Qualifications:

Education: Graduate of a Bachelor’s Degree program in healthcare-related or managerial operations. Master’s degree in

Experience:

A minimum of 5 years’ experience working within an acute care hospital to include a thorough knowledge of the clinical operations of a hospital. Prior experience in organization-wide preparation and survey readiness activities. Knowledge of the organization’s policies and procedures as well as related documents in accordance with regulatory standards.

Demonstrates excellent organizational skills and a proven ability to lead and coordinate projects.
Competent in the analysis, interpretation, explanation and presentation of performance data.
Proven ability to use appropriate verbal, nonverbal, and written communication skills for audiences at all levels of the organization.

Demonstrates the ability to work collaboratively with leaders, practitioners, and health system staff in achieving accomplishments.
Working knowledge of regulatory agency (DNV, Joint Commission), State, and Federal requirements regarding healthcare operations.

Physical/Mental Demands:

1. Ability to think and work effectively under stress with frequent interruptions; to move, sit, stand, walk, and bend intermittently throughout the work day. Lift and/or move up to 25 pounds.

2. Must possess sight/hearing senses or use prosthetics that will enable the applicant to adequately fulfill the requirements of this position.

3. Use of mechanical and technical equipment required for the responsibilities assigned.

4. External and internal applicants who are/become disabled, must be able to perform the essential position responsibilities with unaided or with assistance of a reasonable accommodation to be determined on a case by case basis.

Occupational Exposure to Blood borne Pathogens:

Category I – Tasks that involve exposure to blood, body fluids or tissues.

Orientation Period:

Up to 90 days to perform proficiently all essential position responsibilities. The first ninety (90) days this position is assumed is considered the probationary/introductory period, for which the employee is subject to continuous review.

Essential Position Responsibilities

The essential position responsibilities are the basis for the 90 day and annual evaluation. This list is intended to describe the general nature and level of work to be performed and not intended to be an exhaustive list of all duties required of personnel.

1. Plans and executes short and long term Quality initiatives. Assists CNO with Patient Safety Program initiatives in alignment with organizational goals, as outlined in the annual documents. Assures Quality & Patient Safety work plans and projects include clear measurable goals and monitors results. Communicate trended program measurement outcomes to appropriate business owners to implements process improvements.

2. Investigate quality of care incidents and near misses according to the organization’s established process flows for investigating the following categories of events: Medical Staff or affiliated Practitioner, nursing staff, Provider Organizations (hospital, physician practice and rehabilitation services), continuing care vendors (hospice) and/or Ancillary Services. At least quarterly, produce trended reports, and communicate a clearly developed analysis for actionable interventions by the department(s).

3. Assure periodic reports required for accreditation or Program Office are submitted in a timely manner. Coordinate the completion of the annual documents in collaboration with the Director of Accreditation. Assure maintenance of process flow for investigating CMS Hospital Acquired Conditions (for possible Do No Bill Event) in collaboration with the Claims and Quality Assurance Appeals and Audit Department.

4. Support and participate in quality committees coordinated/facilitated by the department, including Service Quality Resources Management, Safety Systems Steering Committee, Continuing Care Quality Oversight and/or Peer Review Committees and analysis of near misses via root cause analysis.

Job Type: Full-time

Benefits:

• 401(k)
• Dental insurance
• Employee discount
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Ability to commute/relocate:

• Claxton, GA 30417: Reliably commute or planning to relocate before starting work (Required)

Education:

• Bachelor's (Required)

Experience:

• quality, service, safety or accreditation: 5 years (Required)

Work Location: One location

Salary : $80,200 - $102,000