Summary

Works with senior leadership to plan, direct and coordinate the overall quality plan of the organization which includes the collaboration and integration of active working committees and/or individual service areas. Position collaborates with colleagues on management team to improve productivity, processes and patient/resident/customer outcomes.

Specifically coordinates patient satisfaction, peer review, complaint management, to include potential legal action and maintenance of the organizations electronic policy program.

Position actively oversees and processes the collection of quality data, monitors variances from outcomes and conducts key event analysis that will assist with process improvement.

Job Duties

All duties are the essential functions of this job.

• People and Culture: Demonstrates leadership in employee human resource management, healthy and productive department work culture and management of standards of performance and behavior. Create the vision for staff and the framework for services, promotes goal alignment, employee engagement and integration with the team, along with change and conflict management strategies and solutions. Is a good listener and follows through to positive outcomes desired.
• Quality: Demonstrates a priority for process management to align with positive patient outcomes and safety. Uses applicable process improvement tools and methods to continuously improve safety and outcomes within department and across the organization. Continuously learning and modifying processes to grow self and the team, while developing stakeholders to align with change, strategic goals and performance improvement initiatives. Will be responsible to collaboratively manage projects.
• Customer Service: Demonstrated passion for patient/resident centeredness with service. Aligns services, processes and procedures to meet service excellence for patients/residents as well as internal and external customer, vendors and payers. Manages service recovery as well as written and verbal communication from team towards all internal and external customers. Uses service framework in alignment with organizational directives.
• Growth and Facilities: Drives revenue increases and improves efficiency to reduce expenses. Uses systems thinking and collaboratively provides for and supports the marketing of the department and organization. Demonstrate knowledge, understanding and compliance with all regulations set by external regulatory agencies and internal policies. Manages self, and is flexible and able to quickly adapt to and lead change.
• Finance: Demonstrates the ability to plan, execute and monitor departmental financial functions. Prepares and manages budget, resources and assets. Measures and monitors the success metrics for the assigned department.
• Community and Relationships: Demonstrate capacity of connecting with and serving the community and partners with the services of the organization both internally and externally. Supports the mission, vision and demonstrates the values of the organization. Builds trust and cultivates relationships both ethically and professionally. Communicates inclusively and collaboratively with all stakeholders.'

Quality Specific Responsibilities

• Administrator of policy and incident reporting systems and processes.
• Responsible for department surveys and reporting requirements for all quality reporting systems in coordination with revenue team.
• Creates and maintains quality related dashboards and scorecards for the Board of Directors, providers and management.
• Chairs or active participation in Quarterly Quality Meeting, Patient and Family Advisory Committee (PFAC), Safety, Safe Patient Handling, Falls, Workplace Violence, Antibiotic Stewardship and Complaint committees.
• Responsible for all quality related reporting for regulatory agencies.

Required Education and Experience

• Must have a bachelor's degree in nursing (RN preferred), Health Sciences, Quality Management or related field
• Certification and maintenance of Certified Professionals in Heatlhcare Quality (CPHQ) or Certified Manager of Quality/Organizational Excellence (CMQ/OE) required
• Must have at least five years of healthcare experience, critical access hospital system experienced preferred.
• Minimum of one year experience in a previous leadership or supervisory position.

Additional Eligibility Qualifications

• Exception written and verbal communication skills
• Expertise with computer based data
• Customer/Client Focus
• Ethical Conduct
• Initiative
• Personal Effectiveness/Credibility
• Teamwork Orientation
• Technical Capacity
• Time Management
• Quality and Safety focused

Position Type/Expected Hours of Work

Exempt 40 hours per week and may require some flexibility.

Supervisory Responsibility

Direct manager to quality department personnel which may include licensed or non-licensed personnel.