Director (RN) Quality Management

Job Summary

Facilitates alignment between improvement initiatives and the organization’s strategic plan; directs the day-to-day execution of the strategies and tactics necessary to successfully improve the outcomes and results of the organization.

Responsibilities

• Maintains the facilities system-wide Quality program; to include data collection, aggregating and analyzing data, maintaining policies and procedures, and reporting to administrators, Medical Staff, and the Board.
• Works closely with Clinical and Non-Clinical teams for improvement on key performance indicators, designs processes for new initiatives, services and other targets identified by Hospital leadership.
• Serves as an internal consultant to administration, staff, and physicians in the areas of regulatory, process improvement, performance monitoring, and statistical analysis.
• Focuses on better healthcare value and quality, including the improvement of clinical outcomes, patient experience, patient safety, costs, revenue, productivity, efficiency, employee and physician satisfaction, and process reliability.
• Coordinate, manage and report Core Measures, ACO/MIPS/MACRA and meaningful use measures and other quality metrics as assigned.
• Collects and reports HCAHPS data for the facility.
• Organize all Quality Management meetings, maintain minutes and make recommendations to the committee based on best practice and current regulatory standards.
• Conduct internal audits and risk analysis as determined by the Quality Committee.
• Manage and support physician peer review processes by ensuring the collection and analysis of data for provider FPPE/OPPE, scorecards, quality metrics, etc.
• Analyzes all assigned areas for opportunities of improvement and makes applicable recommendations for process, system, procedure, and operational changes to improve healthcare value and quality.
• Assists in the establishment of operational performance measurements and the monitoring of trends in key performance indicators to evaluate effectiveness, reliability, efficiency, etc. using available information systems data.
• Documents the results of projects, and submits other documentation as requested.
• Participates in the Grievance Committee and works with department leaders to resolve investigations within the incident reporting system.
• Evaluate and document the effectiveness of the quality management system.
• Design, coordinate and maintain various aspects of the patient safety and risk management programs for all of the Hospital and its affiliated clinics.
• Review, investigate and analyze incidents for risk and adverse event identification, loss prevention and claims management purposes, including both potential and actual patient injury.
• Recommend interventions which will enhance the safety and well-being of patients, staff and organization at large.
• Mobilize departmental or administrative support to address unresolved high-risk practices.

Qualifications

• Registered Nurse preferred.
• 3+ years experience in a hospital facility required, Quality/Risk leadership experience, preferred.
• Master’s degree in nursing, healthcare administration, or a similar field of study with a strong analytical base, preferred.
• CPHQ (Certified Professional in Healthcare Quality), preferred.

Benefits

• Competitive salary and benefits package.
• Opportunities for professional development and advancement.
• Supportive work environment with a collaborative team.
• Comprehensive healthcare coverage.
• Retail savings plan.
• Paid time off and flexible scheduling options.
• Student loan repayment program.