JOB SUMMARY:

The DQM assumes responsibility and accountability for the hospital-wide Continuous Quality and Performance Improvement program. The DQM will assist the CEO/leadership and Medical Staff to establish priorities for Performance Improvement. He/she ensures that disciplines in the hospital work collaboratively to plan and implement Performance Improvement activities. The DQM will focus on measuring, analyzing and trending information in order to improve outcomes. He/she will assure ongoing monitoring of performance to ensure that improvements are sustained. The DQM will direct and assist in compliance with federal and state regulations and accreditation standards.

ESSENTIAL FUNCTIONS:

Job Specific

• Provides leadership and oversight of a comprehensive, efficient and integrated organization wide Continuous Quality Performance Improvement program.
• Measures and assesses performance through collection, analyses, and trending of data.
• Focuses on processes and systems to improve performance.
• Directs, facilitates, and reports on all aspects of services relating to risk management and patient safety.
• Investigates factors contributing to adverse outcomes in order to improve processes and systems.
• Encourages reporting on risk reduction strategies in an atmosphere which minimizes blame or retaliation. Fosters environment to reduce unanticipated adverse events and/or outcomes.
• Responsible for education of Continuous Quality and Performance Improvement and additional hospital-wide education and training.
• Directs the functions and operation of the hospital-wide continuous quality improvement program including review of records for indicators of quality; reports findings to leadership, Medical Executive Committee, the Board of Managers and other committees as appropriate.
• Responsible for education of Continuous Quality and Performance Improvement to hospital and medical staff.
• Annually reviews hospital wide plans for the functions of IC and CQPI and establishes goals and objectives for the next year.
• Acts as a liaison to local health officials, coordinates inspections and accreditation reviews with state and other regulatory agencies.
• Demonstrates knowledge of growth, development, and the aging process for the planning and delivery of age-appropriate care.
• Other duties as assigned.