Director, Quality Assurance

Essential Functions:

• Ensures compliance with state, federal, and local laws, regulations, and corporate policies. Developing and assisting in the implementation of policies and procedures for quality assurance, improvement, and Joint Commission compliant.
• Regular surveillance of hospital processes, in quality improvement monitors. Serve as a resource to teammates for providers and teammates regarding the specifics of core measures guidelines. (TJC, Quality Net., CDC, FDA, etc.).
• Conducts scheduled Quality/Infection Control rounds on a regular basis, identifying areas for improvement, and educational needs.
• Maintains flexibility when managing multiple roles and responsibilities, responds to changes in nursing practice and develops programs to support those changes, completing assigned tasks and projects in a timely manner.
• Manage incident reporting system by monitoring database to meet current needs, forwarding reports as appropriate, analyzing the data, presenting the results, and suggesting targets for performance improvement based on these results. (RCA)
• Participates in, or chairs committees, work groups, and meetings as deemed necessary. Can demonstrate measurable results and meet target dates.
• Completes performance improvement (PI) audits and assists teammates to make good decisions regarding quality improvement, risk management, and infection control. Responsible for entering data into regulatory data base and submitting data.
• Integrates ethical principles in all aspects of practice.
• Other duties as assigned

EDUCATION

Bachelor’s degree or equivalent minimum experience required.

EXPERIENCE

Minimum of five years of quality experience is required.

REQUIREMENTS

Certified Professional in HealthCare Quality (CPHQ) or equivalent is required.

KNOWLEDGE

• Knowledge of Joint Commission Standards, State regulations, and CMS requirements.
• Knowledge of Quality Improvement planning, including selection of reliable indicators, coordination of monitoring and evaluation activities, and medical record reviews.
• Knowledge of Peri-Operative, Sterile Processes, and Med/Surg processes.
• Knowledge of how to apply principles and statistical methods, including risk stratification, to identify target population, analyze trends and risk factors, and design and evaluate prevention and control strategies.

SKILLS

• Skill in maintaining current knowledge with regards to state and government reporting requirements.
• Skill in gathering/analyzing objective and subjective data regarding quality improvement and infection control needs of organization.
• Skill in effectively communicating with teammates and management both in oral and written form.

ABILITIES

• Ability to interact with management, physicians, and teammates at all levels (i.e. remediation, counseling and as a resource).
• Ability to work in an environment that frequently produces a high level of stress and mental fatigue.
• Ability to establish credibility as the quality control manager and recognizes the needs of the employees.
• Ability to be comfortable performing multiple projects in conjunction with day-to-day activities.