| Summary: Directs and oversees the Division’s systems and processes for hospital quality management. Provides direct supervision, support and clinical/quality expertise to ensure Hospital operational compliance with Joint commission Standards and CMS Conditions of Participation. Essential Functions: Serves as the facility on-site expert of clinical management systems and processes related to meeting Regulatory and Accreditation Standards. Directs the Clinical Quality Review-HD (CQR-HD) process to measure hospital implementation of core clinical programs, screen for potential Special Concern/high risk designation hospitals and monitor effectiveness of corrective actions. Provides oversight and collaboration for regional and Support Center clinical operations staff of Special Concern and other high-risk hospitals (assessment, and validation for designated hospitals). Performs and directs facility-level quality assurance performance improvement through on-site visits and report reviews. Provides review and development of policies, procedures and systems to maintain and verify compliance with Joint Commission and Medicare certification standards. Develops, designs and provides policies, procedures and work processes to ensure adherence to the Quality Council structure, standardized agendas and dashboard reporting process. Reviews and as needed, develops plans of correction in collaboration with regional clinical operations team. Identifies educational content and quality management skills and priorities needed by Directors of Quality Management (DQM), Chief Clinical Officers (CCO) and other key clinical leaders with a strong Quality Assurance/Performance Improvement (QAPI) focus. Facilitates continuing education for field DQMs and regional clinical operations staff. Directs, monitors, evaluates, and makes recommendations for continuous quality improvement. Develops quality management policies, processes and guidelines to improve quality assurance and quality management. Identifies the need for and facilitates continuing education for regional clinical operations staff. Directs, monitors, evaluates, and makes recommendations for continuous quality improvement. Oversees the performance and functionality of the division’s accreditation and certification self-assessment tools, including development of aggregated data and trend reports. Develops and maintains policies and procedures to ensure compliance with local, state, and federal laws regarding clinical quality management and regulatory compliance. Identifies potential risk management situations and reports to appropriate authority. Ensures compliance with company’s confidentiality and release of information policies and procedures. Establishes a team-oriented, efficient, and effective work environment. KNOWLEDGE/SKILLS/ABILITIES: |
Excellent oral and written communication and interpersonal skills. Technical understanding of the federal certification and accreditation standards for hospitals, including enforcement procedures. Proficient in use of the electronic medical record. Proficient in quality management processes and tools including use of Microsoft Word, Excel and QI Macros. Organizes and prioritizes work to meet job demands. Ability to communicate effectively and present information in an organized manner on a routine basis. Effective public communication skills (written, teaching and public speaking). Maintains a good working relationship with peers, superiors and subordinates while working under stressful or emergency situations. Ability to manage several projects/tasks simultaneously. Maintains confidentiality of all patient and/or employee information to assure patient and/or employee rights are protected. Approximate percent of time required to travel: 80% #MON-CORP Education: Bachelor’s degree in nursing or similar clinical discipline required. Masters degree in nursing or healthcare administration or relevant post bachelor’s advance degree preferred. LICENSES/CERTIFICATION:
Licensed in clinical discipline. Certified Professional in Health Care Quality (CPHCQ) or similar certification strongly preferred. EXPERIENCE:
5 years experience leading or providing hospital quality management. Preference for multi-facility responsibilities, nursing leadership and/or regulatory compliance are highly valued. 3-5 years prior manager/director level experience required. Depending on candidate’s qualifications, this position may be filled at a different level.