At ScionHealth, we empower our caregivers to do what they do best. We value every voice by caring deeply for every patient and each other. We show courage by running toward the challenge and we lean into new ideas by embracing curiosity and question asking. Together, we create our culture by living our values in our day-to-day interactions with our patients and teammates.

Job Summary

Responsible for planning and implementing the performance improvement program to meet the needs of the hospital. Provides education to medical staff, hospital staff, and Governing Body. Facilitates performance improvement activities, and CQI activities throughout the hospital. Acts as resource person to administrative team, department manager’s, and medical staff. Performs clinical risk management functions. Assists department managers with preparation for medical staff committees. Oversight responsibility for all regulatory body surveys, such as, JCAHO, State Licensing Review, HCFA (CMS) Validation surveys. Maintains oversight responsibility for all performance improvement activities conducted throughout the hospital. Manages employee health services and the hospital’s Worker's Compensation program. Implements an effective hospital-wide infection control program in keeping with Centers for Disease Control (CDC), JCAHO, and other regulatory agencies

Essential Functions

• Responsible for planning and implementing the performance improvement program to meet the needs of the hospital.
• Facilitates performance improvement and CQI activities throughout the hospital through effective organizational skills and ongoing interaction with clinical chairpersons, nurse managers, ancillary department managers, administrative team, and Governing Body to facilitate the hospital-wide Performance Improvement program.
• Maintains awareness of changes in the regulations and requirements by accrediting bodies and current methodology and practices.
• Manages and operates equipment safely and correctly.
• Communicates appropriately and clearly to physicians, staff, and administrative team.
• Uses database systems to document occurrences, medical staff review functions, committee review and actions. Compiles reports for committees and administrative team.
• Oversees preparation for review by regulatory agencies, educates and assists department managers to maintain appropriate policies and procedures to fulfill requirements and regulations.
• Maintains a good working relationship both within the department and with other departments. Consults with other departments as appropriate to collaborate in patient care and performance improvement activities.
• Participates in risk management and safety activities.
• Provides support and assistance to medical staff officers, committee chairpersons and Governing Body, as required.
• Manages employee health initiatives such as maintaining employee health files, employee TB screenings/chest x-rays, vaccines and the Hebatitis B program.
• Coordinates new employee health screenings.
• Identifies employee illnesses, exposures and injuries in order to assess risk potential for prevention of transmission or recurrences.
• Institutes employee work restrictions if the potential for transmission of infection exists.
• Enters incident/claim information into the Event Reporting System (ERS).
• Acts as a liaison for OSHA or Department of Industry, Labor and Human Relations (DILHR) inspections.
• Maintains the OSHA log.
• Develops, implements and continually monitors the infection control policies and procedures for all departments.
• Implements a surveillance system for detecting and monitoring hospital acquired and community infections. Ensures compliance to regulatory requirements.
• Investigates outbreaks or clusters of infections. Monitors, analyzes, and interprets bacteriology reports and infection statisti