Job Description

Job Location: Gordon Memorial Hospital - Gordon, NE 69343, POSITION SUMMARY

The Quality Improvement Director maintains the responsibility of leading, implementing and monitoring the Hospital Quality Improvement and Assurance Program (QAPI) and Patient Safety Programs, ensuring compliance with regulatory requirements, and driving continuous improvement in care delivery. The role focuses on patient-centered care, performance improvement, and fostering a culture of safety. This position works closely with the Leadership Team, the Board of Directors, and the CEO.

CORE ACCOUNTABILITIES

• Leads/Chairs the Hospital Quality Assurance and Performance Improvement Program (QAPI) committee, including tracking and monitoring all QI projects and reports for departments of the hospital and contracted patient care services, sets meeting agendas, maintains meeting minutes, and providing a routine report to the Board of Directors. Leads annual review of QAPI program.
• Responsible for accurate and timely reporting of Hospital Quality Data to the contracted Quality Improvement Organization (QIO/QIN), Medicaid Directed Payment Program and CMS (MBQIP) per regulatory and contractual requirements.
• Ensures data collection and input for required MBQIP, CMS, CDC NHSN and Flex Grant Quality Metrics, such as Social Determinant of Health Measures (SDOH) screening, Emergency Department Transfer Communication (EDTC), Fall Prevention, Adverse Patient Events, etc.
• Assists with Interoperability reporting and monitoring of Hospital Electronic Quality Measures.
• Maintains the Quality Improvement Dashboard Metrics and collaborates with the Leadership Team and various departments to determine measures to be tracked, target goals and/or benchmarks for the quality measures.
• Educates staff on Quality Improvement Tools and assists them with designing process improvement projects utilizing general QI Principles and tracking data and compiling reports as needed.
• Participates and complies with the Rural Nebraska Health Network (RNHN) and NHA Quality Team requirements.
• Manages the Hospital Compliance Program and serves as the designated compliance officer. Completes required documentation and reporting and assists managers in identifying issues that may adversely affect the hospital’s reputation. Stays knowledgeable on the most current laws, regulations, and conditions set by licensing and regulatory agencies. Ensures adherence to CMS and State of Nebraska Hospital Regulations and facilitates facility survey readiness.
• Serves as the risk management coordinator. Evaluates adverse events, patient safety issues, and patient complaints, maintains records and reports in a confidential manner, and submits occurrences and events as applicable to the malpractice liability insurance carrier or Patient Safety Organization.
• Coordinates the medical case review process and peer review requirements, Coordinates and maintains meeting minutes for the Morbidity and Mortality Committee, maintains case review records, and assists with compiling case submissions under the direction of the medical director.
• Facilitates the policy review and management process, including annual or biennial review of facility policies and procedures by department leadership as required by regulations.
• Supervises the Emergency Preparedness/Safety Coordinator and Infection Preventionist RN.
• Serves as the lead hospital contact for the Hospital Community Health Improvement Plan (CHIP) Process. Assists with data collection and attends MAPP or Planning Committee Meetings as requested by Panhandle Public Health District.
• Performs other duties as assigned.

SCOPE OF IMPACT

This position guides the entire organization on quality improvement, regulatory compliance, and patient safety best practices.

Qualifications: POSITION QUALIFICATIONS

Education

• Graduate of an accredited nursing program, required.
• Bachelor of Science in Nursing, preferred.
• Master’s degree in Nursing, Hospital Administration or Business Administration, preferred.

Experience

• Minimum of three years’ experience in acute care hospital setting required.
• 1 year of management experience preferred.

Licensure and Certification

• BLS required
• Current Nebraska Registered Nurse License strongly preferred.
• CPHQ preferred

Knowledge, Skills, and Abilities

Knowledge of

• Survey standards and the process required.
• Microsoft Office Applications (Excel, Word, PowerPoint)
• The quality improvement process, data collection and statistics.
• Patient Safety principles
• CMS and State regulatory requirements
• Electronic Health Records

Skills in

• Analytical, technological, and interpersonal communication (both verbal and written)
• Project Management and leadership
• Planning and organizing multiple tasks
• Developing education and communicating information to audiences with different needs and education levels.

Ability to

• Deal with stress under pressure.
• Work Collaboratively with staff at all levels of the organization
• Write policies and procedures and maintain documentation which meets or exceeds regulatory requirements.
• Maintain the confidentiality of privileged or sensitive information related to Patient Safety Work Product.
• Utilize critical thinking and problem-solving skills when applying knowledge and experience to quality assessment.
• Develop the programs, processes and procedures for quality improvement.
• To research and locate current regulations and requirements.
• To become CPHQ certified within 2 years of hire.
• Develop policies and procedures using evidence-based practice
• Educate staff in all departments on quality improvement processes, patient safety and risk reduction strategies as appropriate