Director Quality, Clinical Safety & Infection Control

Responsible for directing performance improvement, and clinical safety. Provide leadership and support for the development, implementation, and evaluation of quality improvement initiatives in conjunction with the Administrative team. Direct and manage accreditation, regulation and licensing activities.
Essential Duties and Responsibilities:
Position Specific —
Provides consultation and guidance to the organization and medical staff in the design, monitoring and evaluation of performance improvement activities.
Directs peer review activities in collaboration with physician advisor
Works closely with Medical Director of Quality
Recommends appropriate Process Improvement team formation to the Quality Management and Safety Committee
Acts as facilitator for Process Improvement Teams
Directs the clinical safety program including risk identification, case review, and hospital-wide quality review reporting system\
Collaborates with Claims Management on Quality or Clinical Safety issues.
Provides input at the highest level of Nursing Administration regarding the impact of decisions on the quality of services provided
Serves as an appointed member of the Nursing Leadership Committee as resource and consultant
Oversees and participates in medical record review
Develops and revises organizational policies to assure compliance with current health care law and risk-related issues for Administrative/Board approval.
Directs, coordinates and conducts interdisciplinary intense analysis activities/meetings to establish risk reduction strategies and action plans
Works collaboratively with Nursing Directors to promote standards of nursing practice
Directs the integration of infection control into performance improvement activities
Directs CQI functions of facility to meet Joint Commission, State and Federal requirements for hospital and Medical Staff
Directs survey preparation activities including coordinating mock surveys and organization assessment activities identifying areas requiring improvement
Plans, develops and conducts accreditation and regulation education and orientation activities
Coordinates accrediting and regulatory agency surveys
Coordinates development of written response reports to regulatory and accrediting bodies such as CMS, DHS and Joint Commission.
Provides education regarding current Quality Management regulations for Joint Commission, CMS, Department of Public Health, and insurance providers with employees and Medical Staff
Provides reports on quality activities to the appropriate departments, including the Board of Directors
Protects patient confidentiality
Conforms with Affirmative Action guidelines
Leadership and Management —
Develops and implements departmental goals and objectives with input from staff members
Develops and implements departmental policies and procedures that guide and support the provision of services
Interacts with all customers to ensure prompt and accurate communication as needed to provide the service expected and to meet the goals of the service
Evaluates problems, and develops and implements solutions
Develops new ideas and/or systems with innovation and creativity
Challenges the status quo in looking for more efficient practices
Leads by example and serves as a professional role model
Updates employees on present as well as future changes
Actively listens and tries to understand before responding
Shapes an environment that is psychologically safe, encouraging, and nonjudgmental
Supports, encourages, and contributes to the professional growth of all department employees
Understands, teaches and implements elements of empowerment and team building
Responsible for the maintenance of quality control programs as appropriate
Responsible for the continuous assessment and improvement of the quality of care and services provided
Adheres to all Compliance &
Integrity Program rulesand requirements
Attends and completes Compliance &
Integrity training
Human Resources Management —
Conforms with Equal Employment Opportunity Commission guidelines
Recognizes, appreciates and capitalizes upon the differences people bring to the job
Sees diversity as an advantage
Selects staff who possess and demonstrate the required competencies and values and maintain the Customer Service Expectation and Standards of the hospital
Develops and implements job descriptions and performance standards
Evaluates staff performance per established policy, including the use of staff competence and quality improvement data
Mediates personnel problems and resolves complaints using good problem solving techniques
Demonstrates knowledge of and competently interprets and administers Hospital policies and procedures
Conforms to the hospital Wage and Salary Administration and Recording of Hours Worked policies
Ensures that staff is in compliance with licensure and other annually mandated requirements
Demonstrates knowledge, interpretation and application of the terms and conditions of collective bargaining agreements
Financial Resources Management —
Develops and recommends department operating and capital budgets
Ensures that department operates within established budget
Prepares and manages FTE budget, including developing staffing plans and managing monthly and daily staff schedules
Accountable for unit productivity
Develops and utilizes the budget as a planning and control tool
Develops departmental strategic objectives and new programs
Information Systems Management —
Understands departmental information systems and other equipment as necessary
Understands advanced aspects of various information systems
Understands and conforms to the hospital Information Technology Solutions Group strategic plan
Competence —
Maintains an appropriate level of professional competence by ongoing development of knowledge and skills
Performs professional duties in accordance with relevant laws, regulations and technical standards
Prepares complete, clear reports and recommendation after appropriate analyses of relevant and reliable information
Confidentiality —
Refrains from disclosing confidential information acquired in the course of work, except when authorized and unless legally obligated to do so
Informs subordinates, as appropriate, regarding the confidentiality of information acquired in the course of their work and monitors their activities to assure the maintenance of confidential information
Refrains from using or appearing to use confidential information acquired in the course of work for unethical or illegal advantage either personally or through third parties
Follows Administrative policies on Confidentiality and Privacy Practices
Integrity —
Regularly demonstrates commitment to a set of ethics and values by behaving in an ethical manner that is consistent with the hospital's mission, vision and values
Avoids actual or apparent conflicts of interest and advises all appropriate parties of any potential conflict
Refrains from engaging in any activity that would prejudice the ability to carry out one's duties in an ethical manner
Refuses any gift, favor, or hospitality that would influence or would appear to influence one's actions
Recognizes and communicates professional limitations or other constraints that would preclude responsible judgment or successful performance of an activity
Communicates unfavorable as well as favorable information and professional judgment or opinions in a professional manner
Fully discloses relevant information that could reasonably be expected to influence intended users' understanding of any reports, comments, and/or recommendations presented
Non-Essential Duties:
Other duties as assigned
Knowledge, Skills and Abilities:
Proficiency in the scientific method
Currency in accreditation requirements and processes
Computer literacy
Critical thinking and problem solving abilities
Strong influence/persuasion skills
Assertiveness
Ability to organize information, people and resources
Ability to work collaboratively with and through others
Strong writing skills
Strong presentation skills
Team building skills
Requirements
Education and Experience:
MSN or MS in related field;
condition of employmentto complete within two years
Basic experience or training in statistical methodologies and data analysis
Minimum of seven years of experience in the field or in related area.
Required Licensure and/or Certifications:
QI Certificate and/or equivalent courses
CPR
Maintains competency through appropriate education and training as demonstrated by the following:
Certified Professional of Healthcare Quality Certificate (CPHQ);
or qualified to take exam within two years
Benefits
This is a direct hire opportunity with our client. Full benefits will be offered.
Royalty Medical Solutions is committed to providing an inclusive and welcoming environment for all members of our community and ensuring that no person is excluded from participation in or denied the benefits of our services on the basis of race, color, religion, sex, national origin, age, disability, genetic information, sexual orientation, gender identity, or any other characteristic protected by applicable law. We prohibit discrimination in all its forms and are dedicated to promoting diversity, equity, and inclusion.