Director of Quality Management

About the role

The Department Director is responsible for all quality departmental functions in support of the hospital mission, vision, and facility goals. They identify the cost-effective systems needed to support the business of the department, considering business trends, resource availability, and changes in customers. They establish effective working relationships with all constituencies including patients, physicians, employees, and vendors. They identify and remedy through continuous clinical outcome data and employee involvement.

Responsibilities

• Develops and implements metrics and performance targets that assess compliance with CMS, TJC and ISDH regulations and best practices in medical management.
• Captures improvement activities for successful accrediting, licensing and certification surveys (e.g., Joint Commission, Department of Health, Centers for Medicare/Medicaid Services).
• Affords assistance 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.
• Affords assistance 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.
• Marks trends and emerging issues and presents to quality improvement committee.
• Conducts focused examination of conditions requiring correction and develops a precise definition of the problem.
• Coordinates with providers to communicate and ensure adherence to healthcare quality management guidelines.
• Affords assistance 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.

Requirements

• 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.