Job Description

QUALIFICATIONS

• Bachelor’s degree in health/public health administration, business administration, nursing or closely related area. Master’s degree preferred.
• Three years of progressively responsible experience in the management of quality improvement functions, or nursing quality management.
• CPHQ or equivalent certification preferred.
• Working knowledge of the principles and theories of health care delivery. Considerable knowledge of accrediting (The Joint Commission) regulatory (CMS and other) and licensing agency standards process.
• Demonstrated skill in organizational theories, management techniques, methods, theories and principles.
• Excellent communication skills including a high degree of professionalism.
• Thorough knowledge of OPPE/FPPE; oversee all OPPE/FPPE evaluations
• Proficiency with Epic and MS Office applications including Word, Excel, Outlook, and Power Point.

OCCUPATIONAL EXPOSURE

Office environment

Category II exposure to blood borne pathogens, frequent exposure to chemical hazards and may encounter radiation hazards.

RESPONSIBILITIES:

• Develops, implements, monitors, and assures an integrated and coordinated Quality Program based on the hospital's Quality Improvement/Patient Safety Plan.
• Coordinate activities of the Continuous Quality Improvement Committee and associated activities.
• Supervise Medical Staff and the Quality Team
• Coordinates with and provides leadership to managers and medical staff in adoption of appropriate quality indicators and performance measures, conducting appropriate monitoring and auditing, and documentation, aggregation, and reporting of data, findings, analyses, conclusions, and actions/corrective actions.
• Oversee Peer Review process (OPPE/FPPE) for MEC workflow.
• Provides requested data and reports to support the physician/LIP credentialing and peer review processes.
• Assists with reviews of medical records according to medical staff-selected screening criteria and prepares copies of medical record excerpts for physician and Medical Staff Quality Committee review.
• Oversee Performance Improvement program.
• Directs the Patient Safety function and program. Integrates those functions with Quality Improvement functions. Assure consistency and continuity among all activities. Ensures appropriate reporting of adverse events to external agencies as required.
• Participates in safety/environment of care rounds and certification and accreditation survey readiness activities, coordinating appropriate preventive and corrective action is taken. Implements and follows up on corrective action plans implemented for non-conformities identified.
• Directs all activities associated with accreditation and hospital licensure. Assure consistency and continuity among all activities.
• Develops and maintains professional, organizational, and community relationships.
• Provides service in a manner that is appropriate for the patient’s age; demonstrates knowledge and skills necessary to meet the patient’s physical, psychosocial, educational, and safety needs.
• Presents a courteous and helpful demeanor, appropriate for ages, to all patients, visitors, other facility employees/medical staff members, or any other person and employee encounters while representing the facility.
• Maintains current knowledge related to applicable statutes, regulations, guidelines, and standards necessary to perform job duties in accordance with the requirements of the Corporate Compliance Plan. Complies with the requirements of the Code of Conduct, Corporate Compliance Plan, and Compliance Policies and Procedures, including training requirements. Participates in compliance activities under the direction of the Corporate Compliance Officer.
• Responsible for regulatory compliance as it pertains to all State and Federal regulatory agencies of the Hospital and ASC’s Medical Staff Services.
• Provides planning, designing, integrating, implementing, modifying, and evaluating the effectiveness of accreditation readiness program components, including standard and regulatory compliance to ensure standard compliance is integrated into daily work processes.
• Performs other duties as assigned.

PHYSICAL DEMANDS

• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
• While performing the duties of this job the employee is frequently required to sit, converse, and listen; use hands to touch, handle, or feel objects, tools or controls; and to reach with hands and arms. Specific vision abilities required by this job include close vision and the ability to adjust focus.
• The employee must be able to lift and/or carry over 20 pounds on a regular basis and be able to push/pull over 25 pounds on a regular basis.
• The employee must be able to stand and/or walk at least five hours per day. #100