Director of Quality Assurance

About the role

This position oversees the Quality Assurance/Performance Improvement (QAPI) programs at the Tohono O'odham Nation Health Care (TONHC) Sells Hospital and its four affiliated facilities. The incumbent is responsible for establishing, reviewing, and coordinating Performance Improvement Plans, monitoring compliance with regulatory guidelines, analyzing organizational climate, and implementing strategies to improve patient care and staff satisfaction.

Responsibilities

• Establishes, reviews, and coordinates Performance Improvement Plans for TONHC and related interdisciplinary workgroups and teams.
• Maintains compliance with The Joint Commission and CMS guidelines by reviewing and attending hospital standing committee meetings and department meetings, and conducting reviews of charts, records, and procedures.
• Analyzes organizational climate to determine employee and patient needs, forming the basis for customer relations and staff satisfaction programs.
• Identifies measures or indicators of system performance and actions needed to improve or correct performance.
• Investigates and coordinates the resolution of problems involving patient care.
• Performs tracer methodology reviews as recommended by The Joint Commission.
• Reviews and assesses the appropriateness of patient care and treatment.
• Presents formalized reports with data to governing bodies, leadership, and medical staff.
• Takes steps to optimize resource utilization and ensure compliance with standards of care.
• Works with all departments to develop and review Performance Improvement Reports and data collection.
• Aids staff in making data-driven decisions using performance improvement methodologies.
• Prepares periodic status reports for the Hospital's Leadership Committee and Governing Body.
• Provides orientation, in-service training, and technical assistance to departments on QAPI program methodologies and requirements.
• Maintains the Performance Improvement/Risk Management resource and information center.
• Assesses interrelationships among disciplines and ensures compliance and competence in providing care.
• Executes independent decision-making processes to identify and execute patient care improvements.
• Ensures patient and employee safety through established policies and procedures.
• Monitors and ensures ongoing staff development and education regarding Risk Management processes.
• Ensures compliance with privacy laws and regulations.
• Reviews and reports data to the Leadership Team, Performance Improvement Team, and Governing Body.
• Chairs assigned committees related to performance improvement and strategic planning.
• Works with the Chief Medical Officer and Compliance Officer in monitoring and tracking Tort claims.
• Assists medical and nursing staff in conducting mock exercises and documentation.
• Ensures compliance with Joint Commission Accreditation Standards.
• Conducts audits to ensure compliance with Joint Commission Standards.
• Works with key clinical and other Leadership staff to ensure patient and employee safety.
• Supervises the work of employees.
• Implements overall Quality Assurance/Performance Improvement Plan and Patient Advocacy programs.
• Determines staff and other resources necessary for program operations and adjusts subordinate units as appropriate.
• Establishes or approves overall work schedules and determines individual and group work assignments.
• Conducts meetings and conferences with subordinate staff to explain work requirements, methods, and procedures.
• Reviews, modifies, approves, or rejects changes in functions, procedures, and other matters proposed by subordinates.
• Makes decisions on problems not covered by precedents, protocols, or established policies.
• Reviews and analyzes records, reports, and other data to track department's progress in achieving QAPI objectives and goals.
• Recommends disciplinary actions involving supervised employees.
• Approves, modifies, or rejects career development plans, training requests, employee utilization proposals, and related personnel.
• Approves or disapproves all leave requests for employees supervised.

Requirements

• Master's Degree in Health Care Administration, Nursing, or Business Administration.
• Degree or diploma from a professional nursing program approved by the legally designated State-accrediting agency.
• Four years of experience, education, or training involving principles, techniques, and accepted practices of quality assurance/performance improvement work, preparation of technical reports regarding quality assurance/performance improvement issues, identifying specific problem areas, and providing recommendations for corrective action.
• Three years of supervisory experience.
• Active, current, and unrestricted license as a professional registered nurse in a State, District of Columbia, the Commonwealth of Puerto Rico, or a territory of the United States.
• Certification in Healthcare Cardio Pulmonary Respiration (CPR) and Automated External Defibrillator (AED).

Qualifications

• Knowledge of the Tohono O'odham culture, customs, and traditions.
• Professional knowledge in clinical nursing pertinent to the position.
• Knowledge of the Tohono O'odham Nation's mission, organization, programs, and requirements of a health care delivery system.
• Knowledge of hospital self-assessment programs, accreditation requirements, including quality assurance, risk management, safety/infection control, utilization review, and Medicare compliance.
• Knowledge of governmental and nationwide regulations and standards dealing with regulatory and credentialing groups.
• Knowledge of data analysis and collection techniques to collect and analyze data, identify problems, and establish priorities.
• Knowledge of electronic data collection.
• Knowledge of various functions/departments within the Hospital and motivations of varied employees and groups.
• Knowledge of health and educational resources.
• Knowledge of and skill in using personal computers, various software, and related computer equipment.
• Knowledge of Health Insurance Portability and Accountability Act of 1996 (HIPAA).
• Knowledge of interpersonal skills and ability to establish coordination with the medical staff.
• Knowledge of pathophysiology of disease entities.
• Advanced understanding of current scientific nursing theories, procedures, and techniques used in the care and treatment of all types of patients.
• Ability to recognize deviations from the normal and institute appropriate health services.
• Ability to travel as required within the course of work assignments.

Skills

• Knowledge of the Tohono O'odham culture, customs, and traditions.
• Professional knowledge in clinical nursing.
• Knowledge of the Tohono O'odham Nation's mission, organization, programs, and requirements of a health care delivery system.
• Knowledge of hospital self-assessment programs, accreditation requirements, including quality assurance, risk management, safety/infection control, utilization review, and Medicare compliance.
• Knowledge of governmental and nationwide regulations and standards dealing with regulatory and credentialing groups.
• Knowledge of data analysis and collection techniques.
• Knowledge of electronic data collection.
• Knowledge of various functions/departments within the Hospital and motivations of varied employees and groups.
• Knowledge of health and educational resources.
• Knowledge of and skill in using personal computers, various software, and related computer equipment.
• Knowledge of Health Insurance Portability and Accountability Act of 1996 (HIPAA).
• Knowledge of interpersonal skills and ability to establish coordination with the medical staff.
• Knowledge of pathophysiology of disease entities.
• Advanced understanding of current scientific nursing theories, procedures, and techniques used in the care and treatment of all types of patients.
• Ability to recognize deviations from the normal and institute appropriate health services.
• Ability to travel as required within the course of work assignments.

Benefits

N/A

Pay

$144,409.91 per year

Schedule

N/A