Quality Director

Essential Functions

• Works with VP, Quality and Patient Safety implementing organization-wide quality programs at the hospital level.
• Facilitates the hospital Quality Assessment and Performance Improvement (QAPI) committee.
• Prepares an annual evaluation of the hospital QAPI plan, including process and outcomes.
• Oversees hospital-wide performance improvement (PI) projects identified through on-going data driven quality assessment.
• Covers hospital’s data collection procedures and provides on-going support and education to staff regarding QAPI tools and reporting requirements; utilizes data and collaborates with leadership to set priorities and provide guidance in their development of quality improvement work plans.
• Serves as a resource to the medical staff, administrators and other staff including participation in root cause analyses, as indicated, to investigate potentially avoidable sentinel events.
• Completes assignments accurately, in a timely manner and within procedural guidelines.
• Coordinates education for QAPI principles and regulatory standards as indicated. Conducts training for staff.
• Participates in Joint Commission Accreditation process including plan of action tracking and completion.

Qualifications / Skills

• Demonstrates proficient computer skills with MS office products and electronic QAPI software solutions.
• Ability to create and provide training programs on related quality performance topics.
• Ability to work with minimal supervision and simultaneously manage multiple projects.
• Knowledge of state and federal regulatory requirements, Joint Commission Accreditation.
• CPHQ certification preferred.
• Must successfully complete CPR certification and an Oceans approved behavioral health de-escalation program.

Work Environment

• Subject to many interruptions.
• Occasional pressure due to multiple calls and inquiries.
• This position can be high paced and stressful; must be able to cope mentally and physically to atmosphere.
• Work requires spending approximately 90% or more of the time inside a building that offers protection from weather conditions but not necessarily from temperature changes.