Director of Quality Management (RN) | Heritage Valley LTACH

Director of Quality Management (RN)

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The Director of Quality Management is responsible for the management of efficient, cost effective operations of the performance improvement functions for the assigned PAM Health hospital(s).  Coordination with hospital and medical staff leadership to foster a culture of safety by coordinating the design, measurement, assessment, and planning activities to improve patient care and organization functions.  Serves as a liaison with accrediting and regulatory bodies such as TJC, CIHQ, CMS, and Department of Health.  Provides direction and assistance to the medical staff regarding medical staff quality measures. 

Quality Management

• • Monitors adherence to compliance for  assigned hospital(s) and reports to the Hospital CEO.  
  • Develops and/or maintains reporting systems to provide timely information to administration regarding compliance status with guidelines, rules/regulations and internal policies and procedures. Works with staff so that a systematic process for monitoring and reporting is timely and appropriate
  • Maintains knowledge of state, federal, and local laws and regulations that impact hospital/clinic operations. Demonstrates a working knowledge of accreditation requirements, especially TJC and CIHQ.   Works to ensure the readiness of hospital /clinic for accreditation surveys and other compliance inspections.  Develops and maintains systems for ensuring compliance with laws, rules, regulations and accreditation requirements.
  • Systematically performs on-site surveillance inspections with the Safety Officer and Infection Control personnel in the hospital for the purpose of validating compliance with codes and standards.
  • Coordinates implementation of the hospital’s performance/outcomes improvement plan, consistent with system-wide QAPI plans
  • Collects, analyzes, evaluates, and appropriately reports data relative to performance improvement for inpatient and outpatient facilities throughout the region. Notes trends as they appear and makes appropriate recommendations when opportunities to improve patient care arise.  Regularly reports to administration, assigned committees, locally and at the corporate level.
  • Serves as chairman for the hospital QAPI committee. Assures all minutes and reports of assigned committees are complete and available in a timely manner.
  • Serves as a resource to QAPI teams and department managers in performance improvement process techniques and external agency standards. Facilitates QAPI team meetings, when appropriate, and ensures timely follow-up and reporting.
  • Manages the occurrence monitoring system and ensures timely investigation of incidents to minimize risk to the hospital; keeps Corporate Risk Manager appraised of significant issues in the hospital(s) assigned.
  • Serves as co-chair of the Environment of Care (EOC) committee.
  • Prepares agenda and minutes for meetings for QAPI, and collaborates with the co-chair of EOC.
  • Assists with data collection and ensures overall data collection and score card compliance.
  • Annually reviews /evaluates policies and QAPI plan in conjunction with home office.
  • Responsible for restraint education
  • Facilitates the development of the post survey Plan of Correction.
  • Manages the patient satisfaction program; assures that patient complaints are heard and acted upon in a timely fashion to maximize satisfaction and minimize risk.

Medical Staff QAPI Resource

• • Serves as resource to hospital’s medical staff on compliance and performance/outcomes improvement activities.
  • Assists medical staff in development of compliance and QAPI monitors. Makes recommendations to the Medical Executive Committee and to other appropriate medical staff committees. 
  • Provides quality input for the Medical Staff and Medical Executive Committee meetings. Coordinates staff input and follow-up for all items of committee business.  Ensures recommendations are communicated and actions are recorded in committee minutes
  • Conducts periodic compliance reviews of applications for medical staff privileges, ensuring completeness and compliance with standards such as Medical Staff Bylaws, TJC, CIHQ, and Medicare.
  • Collects data for the ongoing professional practice evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) of medical staff.

 Leadership

• • Inclusiveness: Promotes cooperation, fairness and equity; shows respect for people and their differences; works to understand perspectives of others; demonstrates empathy; brings out the best in  others and in his/her team.