Director of Quality Management - Inpatient Rehab

Location: 300 Market St, Saddle Brook, NJ 07663

About the role

Coordinates the Medical Quality Management and Performance Improvement activities to measurably enhance the quality, process, and cost effectiveness of patient and customer services rendered. Oversees the Performance Improvement and Patient Safety programs in accordance with the guidelines and regulatory requirements of Federal and State regulations on a hospital-wide basis. Oversees operations of the Infection Control and Employee Health Programs. Develops and reviews policies and procedures to ensure compliance with all regulatory and accrediting standards. Collects data to monitor compliance and/or trends. Institutes and monitors the Hospital’s CQI Processes, utilizing data analysis measuring tools.

Assists with the design and compliance of quality processes/activities in the areas of clinical/medical staff PI for all applicable clinical/medical TJC/CARF/DOH standards. Assists with all assigned activities to assure that the hospital maintains accreditation, certification, and licensure. Assumes leadership with the Joint Commission and DOH as well as other regulatory agencies with regard to CQI activities. Serves as a resource for all departments within the facility to provide guidance on designing, implementing, analyzing, and reporting on Quality Improvement.

Assists clinical areas in developing criteria, monitoring and reporting mechanisms, and action documentation related to the hospital’s CQI program. Performs basic chart review activities with appropriate staff for outcome utilization, infection control, and medical CQI indicators. Analyzes results of chart review activities with appropriate staff and confers with department staff on any case requiring special attention. Prepares analysis of significant PI findings pertaining to adverse drug reactions, drug usage evaluation, medical management of acute transfers, and other CQI indicators.

Responsibilities

• Coordinate Medical Quality Management and Performance Improvement activities to enhance quality, process, and cost effectiveness of patient and customer services.
• Oversee Performance Improvement and Patient Safety programs in compliance with Federal and State regulations.
• Manage operations of the Infection Control and Employee Health Programs.
• Develop and review policies and procedures to ensure compliance with regulatory and accrediting standards.
• Collect and analyze data to monitor compliance and trends.
• Institute and monitor the Hospital’s Continuous Quality Improvement (CQI) Processes using data analysis tools.
• Assist with design and compliance of quality processes for clinical/medical staff PI, ensuring adherence to TJC, CARF, and DOH standards.
• Support activities to maintain hospital accreditation, certification, and licensure.
• Lead interactions with the Joint Commission, DOH, and other regulatory agencies regarding CQI activities.
• Serve as a resource for departments on designing, implementing, analyzing, and reporting Quality Improvement initiatives.
• Assist clinical areas in developing criteria, monitoring, reporting mechanisms, and action documentation for the CQI program.
• Perform chart review activities for outcome utilization, infection control, and medical CQI indicators.
• Analyze chart review results and confer with department staff on cases requiring special attention.
• Prepare analyses of significant Performance Improvement findings, including adverse drug reactions, drug usage evaluation, and medical management of acute transfers.

Requirements

• Registered Nurse with a valid state license (legacy employees may have other clinical licensure).
• Experience in at least one of the core areas of responsibility: Quality, Survey Readiness, Risk Management, Infection Control, Employee Health, or Education.
• Familiarity with accrediting standards, including TJC and CARF (preferred).

Preferred Qualifications

• Previous experience in Quality Improvement, with Statistical Process Control experience and computer skills.
• Certified Professional in Healthcare Quality (CPHQ) preferred.

Pay

$108,000 to $140,000 plus annual bonus incentive.

Benefits

• Extensive onboarding and training program.
• Customizable health insurance packages.