Job Description
Job Description
Job Summary
The Director of Quality and Patient Safety is responsible for leading and overseeing the hospital’s quality management program, ensuring the delivery of safe, effective, and patient-centered care. This leadership role includes developing and implementing strategies to drive continuous improvement, maintain accreditation standards, and promote a culture of excellence.
Essential Job Responsibilities
- Promote the mission, vision, and values of the organization
Quality Management & Improvement :
Lead the design, implementation, and monitoring of hospital-wide quality initiatives aligned with national, state, and local standards.Develop and oversee quality improvement programs that focus on reducing clinical errors, improving patient outcomes, and ensuring compliance with accreditation standards (e.g., CIHQ, CMS, etc.).Monitor, collect, analyze, and report core measures, electronic clinical quality measures (eCQMs), Meaningful Use metrics, and Inpatient / Outpatient Quality Reporting (IQR / OQR) measures in compliance with regulatory and organizational requirements.Participates in Clinic quality improvement initiatives (e.g., MACRA, MIPS, ACO, etc.).Establish and track quality metrics, performance dashboards, and data analysis systems to identify areas for improvement and guide decision-making.Collaborate with clinical and administrative teams to implement evidence-based practices and drive improvements in care delivery.Manages and supports physician peer review processes by ensuring the collection and analysis of data for provider FPPE / OPPE, scorecards, quality metrics, etc.Patient Safety & Risk Management :
Implement robust patient safety programs to identify, prevent, and mitigate risks across all departments.Lead root cause analyses (RCAs) and failure mode effect analyses (FMEAs) to investigate adverse events, near-misses, and patient safety incidents.Ensure the development and implementation of corrective action plans in response to identified risks and safety concerns.Promoting Just Culture :
Advocate and model a Just Culture framework that encourages open reporting of incidents and near-misses without fear of retribution.Foster a non-punitive environment where employees are supported to speak up about safety concerns, learn from mistakes, and contribute to quality improvement efforts.Educate staff at all levels about the principles of Just Culture , emphasizing shared accountability for both individual actions and system-level issues.Regulatory Compliance & Accreditation :
Oversee preparation and lead efforts for hospital accreditation and certification surveys, ensuring the hospital meets all regulatory and quality standards.Ensure ongoing compliance with state and federal regulations, including infection control protocols, patient safety standards, and documentation requirements.Prepare and submit reports for regulatory agencies and accreditation bodies, ensuring timely and accurate communication.HCAHPS and Patient Satisfaction Initiatives
Oversee the hospital’s Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) program and other patient satisfaction data to ensure accurate data collection, analysis, and reporting.Provide staff education on the impact of HCAHPS scores, emphasizing the importance of service excellence and associated reimbursement.Utilize patient satisfaction survey data to identify trends, set benchmarks, and develop targeted improvement initiatives.Facilitate Patient and Family Advisory Council (PFAC) and Patient Excellence Committee (PEC) to align practices with patient-centered care principles, encourage active involvement of patients and families in care processes, including feedback mechanisms to address concerns and improve services.Data-Driven Decision Making & Reporting :
Lead the collection, analysis, and reporting of key quality metrics to senior leadership, physicians, and staff, utilizing effective methods to enhance clarity, facilitate understanding, and maximizing practical value.Utilize clinical and operational data to identify trends, measure performance, and drive continuous improvement.Present findings and recommendations at board meetings and other hospital forums, keeping stakeholders informed about the hospital’s quality initiatives and progress.Education & Staff Development :
Develop and deliver educational programs to promote awareness of quality initiatives, patient safety, and the principles of a Just Culture .Provide coaching and mentorship to quality management staff and hospital teams, empowering them to take ownership of quality improvement efforts.Collaborate with training departments to ensure all staff receive timely and relevant education on quality standards, safety protocols, and regulatory requirements.Department Director Functions :
Facilitates alignment between improvement initiatives and the organization’s strategic plan; directs the day-to-day execution of the strategies and tactics necessary to successfully improve the outcomes and results of the organization.Completes annual performance evaluation for self and employees and implement plans of correction when needed.Manages a departmental budget; leads cost efficient and effective operations, creates plan of correction for any operating expenses that deviate more than 10% from budget.Uses problem-solving and conflict resolution skills to foster effective work relationships with team members.Maintains required competencies for self and all employees within the department.Pursues professional growth and participates in a professional organization.Non-Essential Functions
Performs other duties as assigned.Roosevelt General Hospital (RGH) is committed to providing safe, quality care to patients. Employees are required to adhere to the Values of RGH.
Integrity
We are committed to honesty and ethical principles, where our words and actions reflect our dedication to fostering strong relationships and maintaining professional credibility.We take accountability for our actions and their impact on others, consistently honoring our commitments and upholding moral standards and values in every situation.Learning
We promote personal growth and professional excellence by embracing continuous learning through training, mentorship, and constructive feedback.We foster a collaborative culture driven by curiosity and critical thinking, encouraging staff to ask questions, seek answers, and share knowledge.Innovation
We confidently embrace changes in technology, processes, and practices, encouraging strategic risk-taking and creativity to enhance healthcare delivery, patient safety, and the quality of care.We collaborate with partners from other hospitals, academic institutions, industry leaders, and community organizations to promote continuous improvement and remain at the forefront of advancing healthcare outcomes.Kindness
We engage in open communication with patients, families, and colleagues to understand their needs and concerns, while respecting their differences and upholding their dignity.We foster a nurturing environment where individuals feel supported, understood, and valued, strengthening relationships, promoting growth, and enhancing the overall well-being of all.Excellence
We strive to be a model rural healthcare facility, setting high standards in healthcare delivery and ensuring exceptional patient satisfaction within the communities we serve.We take pride in our accountability and fiscal responsibility, skillfully balancing costs and outcomes to guarantee that superior patient care is always delivered.Unity
We collaborate across departments and disciplines to deliver effective and compassionate healthcare, working alongside patients, families, and community partners to ensure seamless coordination of care and achieve our common goals of wellness and healing.We prioritize open communication and mutual respect, empowering our teams to collaborate effectively by acknowledging and celebrating the unique contributions and strengths of each individual.Qualifications
Bachelor’s degree in nursing, healthcare administration, or other clinically focused field with a strong emphasis on analytical skills requiredA minimum of three (3) years’ experience in a hospital facility required, quality management and patient safety experience, preferredMaster’s degree in nursing, healthcare administration, or other clinically focused field with a strong emphasis on analytical skills preferredBasic Life Support certification required within 30 days of hireProfessional Requirements
Adhere to dress code, appearance is neat and clean.Complete annual education requirements.Maintain patient confidentiality at all times.Report to work on time and as scheduled.Wear identification while on duty.Maintain regulatory requirements, including all state, federal and local regulations.Represent the organization in a positive and professional manner at all times.Comply with all organizational policies and standards regarding ethical business practices.Communicate the mission, ethics and goals of the organization.Participate in performance improvement and continuous quality improvement activities.Attend regular staff meetings and in-services.Knowledge, Skills, and Abilities
Knowledge of CMS and CIHQ standards and regulations.Knowledge of and skill in applying and teaching a wide variety of improvement methodologies and tools including but not limited to Lean Management principles, Root Causes Analyses (RCA) and Aggregate RCAs, Healthcare Failure Effects Modes & Analysis (HFEMA).Knowledge of the application of the best tool / graph / visual to use for specific data sets and statistical analysis (e.g., pareto charts, fishbone diagrams, process and value stream mapping, etc.)Knowledge of system process analysis, quality / process improvement techniques, design, and integration, at a level of complexity associated with integrating processes across multiple departments of an organization.Possess a level of analytical ability to problem-solve, evaluate, plan, and direct process improvement projects and benchmarking activities for all clinical and non-clinical departments.Skill in organizing and prioritizing workloads to meet deadlines.Ability to develop policies and procedures.Ability to teach and evaluate clinical performance.Ability to compile, code and categorize, or verify information / dataStrong organizational and interpersonal skillsAbility to determine appropriate course of action in more complex situationsAbility to work independently, exercise creativity, and maintain a positive attitudeAbility to manage multiple and simultaneous responsibilities and to prioritize scheduling of workAbility to maintain confidentiality of all medical, financial, and legal informationAbility to complete work assignments accurately and in a timely mannerAbility to communicate effectively, with excellent verbal and written communication skillsAbility to handle difficult situations involving patients, physicians, or others in a professional mannerPhysical Requirements and Environmental Conditions
Working irregular hoursWork in varying degrees of temperature (heated or air conditioned).Work under extreme pressure.Exposure to blood and body fluids, communicable diseases, chemicals, radiation, and repetitive motionsPosition requires reaching, bending, stooping, and handling objects with hands and / or fingers, talking and / or hearing, and seeing.
