Quality Assurance-Director of Quality FT/DAYS

JOB SUMMARY: The Director of Quality works collaboratively with MMHS Executive Team, leaders, physicians and staff to reduce patient, guest, and employee risk and to promote quality patient care and safety. This is accomplished through various assessment activities, process improvement activities and through committees or meetings including Quality, Patient Safety, Corporate Compliance, Complaints and Code Blue. Directs and leads all compliance, quality and risk management activities for MMHS including patient care and relations, and accreditation/licensing survey readiness. Develops strategic plans and policies for improved quality throughout the system and works with leaders to ensure compliance with regulatory agencies. Manages and coordinates efforts to ensure that quality management programs are developed and managed using a data driven focus and sets priorities for improvements aligned to ongoing strategic imperatives. Duties include oversight of Risk Management and Compliance.

This position exists 1) as a channel of communication to receive and direct quality, risk and compliance issues to appropriate MMHS resources for investigation and resolution, and 2) as a final internal resource with which concerned parties may communicate after other formal channels and resources have been exhausted. Will work closely with other management who are responsible for ensuring the organization complies with Joint Commission, Health Insurance Portability and Accountability Act (HIPAA), and applicable accreditation standards.

PERFORMANCE DIMENSIONS AND TASKS
Essential Function
1. On-going assessments of regulatory related, performance improvement and risk management compliance policies and procedures and assist in updating or developing new policies to enhance this positions’ areas of operations.
2. Carry out a vulnerability analysis on the organization’s quality programs and activities, discover areas of potential risk and vulnerability, and create and implement solutions to quality measures compliance.
3. Manage and direct healthcare training and educational programs to advance awareness, education, and readiness for Joint Commission and other related agency-audit visits.
4. Conduct or delegate investigations, and coordinate internal and external corrective measures to be executed relative to identified deficiencies noted in quality adherence.
5. Establishes and maintains a mechanism to track quality related information and review or receive a report on the findings of such activities.
6. Stay informed of current quality issues affecting the healthcare industry, as well as quality program best practices.
7. Prepare report for management on incidents arising out of deficiencies related to quality, investigations, and all significant quality deficiencies with recommendation(s) to resolve.
8. Carry out due diligence on new healthcare businesses/services before they are implemented and design effective quality assurance plans.
9. Accurately, timely, and with due diligence will assist in the preparation and presentations for Joint Commission and other related surveys reflecting compliance to clinical and non-clinical integration of standards. Identifies deficiencies and assist in remedial resolution of such.
10. Champions clinical quality performance and patient safety, to meet established patient safety, quality and compliance goals across multiple communities.
11. Directs the development of programs and processes related to Performance Improvement across multiple employee populations based on the unique volume and services at each site.
12. Provides education to all quality leadership and executives.
13. Facilitates organization wide transition to a High Reliability Organization through development of policies, standards, indicators, implementation and evaluation techniques.
14. Develops policies and procedures, monitors performance, develops and reviews metrics, assesses and prioritizes risk, and reports results to leadership. Serves as a resource to quality teams, medical staff and executives.
15. Develops and maintains quality and patient safety plans that align with the organization and are relevant to the unique volumes and services at each site.
16. Develops and maintains a process that engages system and site leaders in the periodic assessment and prioritization of system-wide quality initiatives.
17. Supports sites in scope in developing and building meaningful reports for the quality subcommittee of the board and other leadership committees.
18. Facilitates development of proactive programs that use standardized Performance Improvement (PI) and Root Cause Analysis (RCA) techniques to minimize risk.
19. Proactive evaluation of safety and near miss events, cost, place, treatment, for the purpose of making recommendations for improvement using standardized Performance Improvement (Pl) and Root Cause Analysis (RCA) techniques. Supervises accreditation program and ensures ongoing preparedness for meeting requirements for regulatory and licensure.
20. Oversees the Infection Prevention program for the organization.
21. All other duties as assigned.

QUALIFICATIONS
Education:
• Bachelor’s Degree in a healthcare related field – Required
• Master’s Degree in healthcare or an organizational leadership field.-Preferred

Work Experience:
• Minimum three years, recent full-time experience in managing a healthcare facility’s Performance Improvement, risk and compliance activities– preferred.

Licensing Requirements:
• Current State License in a clinical field - Preferred
• Certified Professional in Healthcare Quality (CPHQ), or Healthcare Quality and Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment. – Obtained within one (1) year of hire - Required

Language Requirements:
• None

Physical Demands:
• Must be able to sit and stand/walk for long periods of time.
• Must be able to lift and carry up to 30 pounds.
• Moderate exposure to hazardous waste and chemicals.

Special Demands:
• Ability to supervise and work cooperatively with others.
• Must be able to delegate duties and maintain efficient standards of operation.

DISCLAIMER: The preceding job description has been designed to indicate the general nature and level of work performed. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this job.