Director of Quality Improvement

Job Summary

The Director of Quality will be a Member of the Senior Leadership Team at Preston Memorial Hospital with reporting relationships both to the PMH Chief Executive Officer and Mon Health System Quality Leadership. The Director of Quality is responsible for providing overall vision and direction for all aspects of quality, patient safety and process improvement for Preston Memorial Hospital, and also serve as a vital member of the Mon Health System Quality team to ensure alignment with Mon Health System Quality programs and initiatives.

The Director of Quality ensures that the organization provides the highest quality care in a safe, timely and patient centered manner. Provides executive leadership and direction ensuring the organization meets accreditation and regulatory standards and fulfills reporting requirements. Develops and expands continuous clinical performance improvement through the setting of priorities, allocation of resources, oversight of policies and procedures and the setting and execution of strategic plans.

This position will also provide facility support for the Mon Health System led compliance and risk management programs; to include compliance, risk and legal issue reporting, coordinating systems for compliance and risk identification, investigation and analysis; and coordination of education.

Responsibilities

People and Culture

· Effectively manage activities of department staff

· Maintains staff performance results by coaching, counseling and disciplining employees; planning, monitoring and appraising job results

· Maintains and supports staff in professional and technical knowledge by educational conference attendance; professional network establishment; and professional organization participation

· Develop and foster effective collaboration between clinical departments to ensure an integrated approach to quality, safety and performance improvement.

· Communicate effectively to facilitate positive working relationships and achieve desired outcomes

· Provide hospital quality and performance improvement education to the workforce including the medical staff

Integration and Efficiency

· Oversee the processes that provide relevant reports, data and education to support quality improvement and fulfill reporting needs. Reporting needs include national benchmark surveys, national rankings, accreditation requirements, third party payor requirements, regulatory agency requirements, peer review.

· Monitor and evaluate and improve activities related to the quality of patient care. This includes benchmarking activities with CMS and any other vendors or agencies utilized.

· Meet regularly with Senior Leaders, Medical Staff members, and other Department Management to provide detailed reports on all serious incidents, claims, risk-related issues; submit monthly incident reports, as applicable, to the Credentials and Review Committee.

· Prepare reports to appropriate Committees on processes for improvement, trends and actions identified by the Quality Department.

· Assists the Corporate Compliance Officer with maintaining an effective compliance communication program for the organization, including promoting (a) use of the Compliance Hotline; (b) heightened awareness of Standards of Conduct, and (c) understanding of new and existing compliance issues and related policies and procedures.

· In coordination with the MHS Compliance Officer, monitors and reports the performance of the Hospital Compliance Program and related activities on a continuing basis, taking appropriate steps to improve its effectiveness.

· Collaborates with other departments (e.g., Risk Management, Internal Audit, Human Resources, etc.) to direct compliance issues to appropriate existing channels for investigation and resolution. Consults with the Corporate attorney as needed to resolve difficult legal risk/compliance issues.

· Identifies potential areas of compliance vulnerability and risk; develops/implements corrective action plans for resolution of problematic issues and provides general guidance on how to avoid or deal with similar situations in the future.

· Management of the compliance Hotline.

Financial Vitality

· Achieves financial objectives by preparing an annual budget, scheduling expenditures, analyzing variances, and initiating corrective actions.

· Ensure appropriate allocation of resources to support the quality and safety agenda.

Quality and Safety

· Develop, modify and maintain a written performance improvement plan that is reviewed annually and submitted to the Board of Directors for approval.

· Develop and lead the overall hospital quality improvement program. Assist all departments in developing their performance improvement and act as a consultant to departments and medical staff to define appropriate action plans.

· Establish guidelines for the reporting of serious incidents. Supervise the maintenance of the computerized incident report database. Ensure all reports are completed per policy and risk events are accumulated and reported to the appropriate groups as noted below.

· Utilize the results from performance improvement activities to improve processes that affect patient care outcomes.

· Coordinate the agenda for the Quality Committee of the Board of Directors with the committee chairperson. A report must be given at least quarterly to Credentials and Review Committee of the Medical Staff and to the Quality Committee of the Board of Directors.

· Immediately report to the Chief Executive Officer any serious incident/complaint representing actual or potential patient, visitor, and/or employee injury.

· Monitor overall compliance with all regulatory standards, particularly the State Department of Health and Human Resources and ensure the hospital is always in a state of readiness to meet Medicare conditions of participation.

· Submit summary report on serious incidents and claims on individual physicians to the Credentialing Office prior to the reappointment process.

· Maintain the risk investigation reports of all potentially compensable events (patient, visitor, employee, product); submit quarterly reports to the Credentials and Review Committee of the Medical Staff and Board of Directors on the actions taken to minimize risks, as applicable. All such reporting should be considered labeled as CONFIDENTIAL for Peer Review purposes or under an Executive Session of the Board.

· Reports alleged violations of rules, regulations, policies, procedures, and Standards of Conduct to the System Compliance officer.

· Monitors, and as necessary, coordinates compliance activities of other departments to remain abreast of the status of all compliance activities and to identify trends.

· Ensures proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required.

Growth and Development

· Guide and lead the Department Managers to better understand quality of care and performance improvement initiatives.

· Utilize improvement techniques such as LEAN and Six Sigma to improve throughput of patients in various touch points in the hospital.

Knowledge, Skills & Abilities

Seven (7) years of experience in Quality, Compliance and/or a related field, three (3) of which in a management role, is required.

Experience in a quality leadership position preferred.

Education

Bachelor of Science in Nursing from an accredited nursing program or a similar field of study with a strong analytical base, required.

Advanced Lean and Six Sigma training preferred.

Certified Professional in Healthcare Quality preferred

Credentials

• Registered Nurse (Required)

Work Schedule: Days

Status: Full Time Regular 1.0

Location: Preston Memorial Hospital

Location of Job: WV:Kingwood:Preston Memorial Hospital