Director of Quality and Patient Safety - TRAVEL

• Responsible for leading the development, implementation, and monitoring of quality and safety programs within the organization.

• Provide leadership and guidance in quality improvement, initiatives, patient safety measures, risk management and clinical performance monitoring.

• Ensure that patient safety initiatives and quality of care are aligned with national, state, and local regulatory standards, accreditation bodies, and payor contracts (e.g., Joint Commission/CARF, Payors etc.).

• Identify, assess, and prioritize facilities in the areas of quality improvement, risk, survey preparedness, and clinical programming.

• Provide support for facility Quality/Compliance/Risk functions by assisting with onboarding De Novo projects, acquisitions, and existing facilities.

• Assist facility staff in coordinating the investigation, processing, and defense of complaints for accrediting bodies, regulatory agencies and MCOs.

• Monitor the timely submission and trending of required report to external agencies and internal corporate entities.

• Complete onsite visits to assigned facilities to assist with quality improvement, survey preparation, regulatory compliance, and patient safety initiatives.

• Responsible for completion of standardized compliance audit and follow-up.

• Assist with review and development of policies and procedures and EMR/documentation.

• Ensure Quality Meetings/Committee of the Whole/Governing Board are occurring timely as required.

• Provide orientation and on-going training to facility QI/Risk Management Directors/Managers and as needed to facility leadership, including, but not limited to CEO, DON/CNO, Clinical Director, Plant Operations, and Infection Control.

• Design, implement, and evaluate quality improvement programs to improve patient outcomes.

• Identify and address trends in clinical outcomes, patient safety events, and quality deficiencies and assist with corrective action plan implementation and monitoring.

• Monitor the effectiveness of quality improvement initiatives and safety programs, adjusting strategies as needed.

• Oversee and participate in risk analyses for patient safety incidents, ensuring corrective actions are implemented, tracked, and that follow-up is being completed.

• Collect and analyze data related to quality and patient safety metrics, audits, to include patient outcomes, incident reports, and clinical performance.

• Develop and oversee ongoing education and training programs for clinical and non-clinical staff on quality and patient safety practices.

• Support the VP of Quality and Patient Safety with various projects, meetings, and reports as required.

Education/Experience/Skill Requirements:

• Bachelor’s Degree in Nursing or Human Services field required. Master’s Degree in Human Services preferred.

• Four or more years’ experience in Quality Management, PI role, hospital licensure, survey and credentialing process required.

• Professional clinical license preferred.

• Two or more years’ supervisory/management experience preferred.

• Experience with TJC accreditation and regulatory audits preferred.

• Working knowledge of Regulatory Compliance.