Director, Quality Services

Hours of Work :

40 hours per week

Days Of Week :

Monday - Friday

Work Shift :

Job Description :

Your Job:

Job Purpose: The Director Clinical / Quality Management is responsible for conducting assessments of medical STAFFnd hospital clinical outcomes, identifying opportunities for improved patient safety, clinical quality, operation performance, and facilitating processes to prioritize and act upon improvement priorities. The Director Clinical / Quality Management will incorporate the clinical and operational benchmarking systems, patient safety program, regulatory organizations' quality / patient safety requirements, and Joint Commission readiness in the assessment, prioritization, and improvement initiatives. The Director Clinical / Quality Management is responsible for communicating and reporting medical STAFFnd hospital performance related to quality, clinical outcomes and patient safety to the medical staff, hospital staff, and administration. The Director is responsible for assuring that data required for submission to meet regulatory requirements is valid, reliable, accurate, and timely. The Director will be responsible for coordinating efforts to maintain organizational compliance with Joint Commission standards related to medical staff, performance improvement, and national patient safety goals.

Knowledge and Experience Required:
Related Work Experience:

• Minimum five (5) years work experience in health care quality management, quality improvement, clinical outcomes, or hospital performance improvement

Education:

• BA / BS degree required

Licenses and/or Certifications Required:

• Certified Professional in Health Care Quality - CPHQ and/or CPPS
• Certified Risk Management, or Infection Control

Licenses and/or Certifications Preferred:

• If basic education relates to a licensed health profession, then license must be current

Job Responsibilities:

• Coach, mentor, and develop staff: Establish, in conjunction with MHS values, policies, ethics, and departmental operating guidelines; Establish and communicate department goals and accomplishments, incorporation individual and team efforts in formal and informal feedback and recognition programs; Create an atmosphere of collaboration within the department and organization.
• Coordinate and/or assist with the implementation of programs to improve patient safety: Analyze occurrence reports, near miss reports, sentinel events reviews and failure mode effects analysis to identify areas of actual/potential of patient safety hazards; Uses reports from other sources for organizational application and adoption of patient safety practices (e.g. Web M&M, ISMP, Joint Commission, Leapfrog, National Quality Forum, Institute for Healthcare Improvement); Facilitates organizational prioritization of patient safety initiatives; Coordinates organizational adoption of national patient safety goals.
• Facilitate / co-lead clinical improvement teams, fostering identification of needed improvements and integration with interdisciplinary teams as needed: Develop education and development program to assist managers, directors, supervisor, staff, and physicians to effectively respond to identified improvements required; Directs, manages, and maintains the medical staff peer review process of medical staff members on a current basis and reports medical staff issues as required.
• Integrate benchmarking, hospital quality initiatives, medical management, patient safety and JCAHO preparation with medical STAFFnd hospital quality initiatives: Educate medical STAFFnd hospital staff regarding performance improvement processes/initiatives; Anticipate and integrate quality measures, which may be publicly reported or will tie to pay for performance for the hospital or medical staff, into ongoing assessment and improvement activities; Assure timely and accurate data collection to meet requirements for state, federal, other initiatives (e.g. Hospital Quality Initiatives); Develop a systematic approach to use of benchmark data by the medical STAFFnd hospital staff which will result in and support prioritization of needed improvement activities; Assure that prioritized performance improvement initiatives are supported by appropriate structure, charters, methodologies, accountability and feedback mechanisms; Evaluate effectiveness of performance improvement efforts; Revise performance improvement methods to achieve targeted results.
• Maintain current knowledge of federal, state, hospital and Joint Commission standards related to quality, clinical outcomes, and patient safety: Coordinate and/or assist with policy/guidelines development to assure compliance with external regulations; Coordinate and/or assist wi