Directing the overall operation of quality, infection control, regulatory, patient and employee safety, risk management, and compliance and privacy departments and clinical areas is the core of this leadership role. The Director of Quality provides organizational leadership for performance improvement, fostering collaboration across departments to ensure a quality-focused approach to services and fulfilling quality objectives. This role functions as a liaison between medical staff, nursing administration, and hospital leadership, developing strategies to improve overall performance and serving as a resource to reduce costs, enhance revenues, and achieve quality goals.
Responsibilities
Administratively direct all aspects of Quality, Patient and Employee Safety, Infection Control, Regulatory, Policy Management, Risk Management, and/or Compliance and Privacy
Lead by influence for effective Emergency Management and Life safety to assure a hospital environment consistent with objectives
Direct quality and regulatory through hospital administration and directors
Participate in operational planning and develop goals and objectives for areas of accountability
Influence the establishment of standards of nursing practice and other clinical procedures within the hospital
Direct regular review of safety and quality outcomes and performance for hospital strategic plans
Direct and maintain application of the continuous improvement process in management of patient care delivery
Direct the preparation, control, and monitoring of budgets for assigned areas
Assure compliance with targeted fiscal objectives; discuss budget variances and modification as necessary with executive leadership
Recruit and develop staff necessary for effective leadership and management of departments to achieve hospital quality and safety goals and regulatory requirements
Establish and maintain standards for employee relations, motivation, and morale throughout the organization
Participate with governing body, management, medical staff, and clinical leaders in the organization
Collaborate with department managers and administrative team to provide recommendations for the annual operating and capital budget
Lead Risk Management administrative activities by ensuring policy renewals and reporting issues to the carrier and maintaining all related records and documents
Direct the Policy Committee and interpret hospital policies and procedures for administrative staff; implement new or modified policies and procedures as necessary
Assure applicable accreditation, licensure, and regulatory standards compliance
Present evidence-based indicators and standards to measure, assess, and improve quality patient outcomes and work collaboratively with departments to approve and implement these initiatives
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Oversee and manage the administration, coordination, performance, and monitoring of operational and business activities of the entity
Work with leadership to identify improvement priorities and goals and partner with them to deliver improvements to clinical and operational processes
Implement and manage clinical procedures and regulatory processes relating to patient flow and budgets
Develop and foster effective collaboration between clinical departments and divisions to ensure an integrated approach to quality, safety, and performance improvement
Oversee the processes that provide relevant reports, data, and education to support quality improvement and fulfill reporting needs
Support key committees pertaining to investigation of sentinel events, safety concerns, and identification of event trends
Oversee the development and implementation of evidence-based medicine practice guidelines
Ensure compliance with relevant licensing, regulatory, and accreditation requirements
Maintain knowledge and expertise in regulatory change
Assist in the development, coordination, and management, with the Emergency Management Director/Manager, the Emergency Operations Plans (EOP) and associated annexes and supporting policies
Work with the Emergency Management Director/Manager and hospital's education staff to design, develop, coordinate, and implement hospital-wide and site-specific training for the hospital EOPs
Assist and direct, with the Emergency Management Director/Manager, the execution of required hospital Emergency Preparedness
Represent hospital at external meetings and venues at the local, regional, and state level
Develop and maintain a routine reporting process to the Board of Directors and administration with timely and relevant information on the status of programs and periodic risk assessments on all compliance issues
Coordinate and provide assistance with WVU Medicine
Requirements
Bachelor
's degree in nursing, business administration, finance, accounting, or other related field
Five (5) years
' experience working with hospital operations with a focus on quality improvement
Three (3) years
' experience in leadership
Nice to have:
Master
's degree in business administration, finance, accounting, or other related field
Current licensure or temporary licensure as a Registered Professional Nurse
Ten (10) years
' experience working with hospital operations including at least three (5) years
' experience in Administrative Management
Experience in applying Lean Management approaches to process improvement
Knowledge of financial mechanisms of expense and revenue
Knowledge of current theoretical approaches to the delivery of nursing care and strategies for their implementation
Knowledge of current leadership, management, and performance improvement concepts
Knowledge of the scope and complexity of nursing care needs of the hospital
Ability to investigate complaints, incidents, and accidents involving all patients and staff in accordance with hospital policy
Ability to make decisions and use good judgment
Multi-tasking, problem-solving, and decision-making abilities
Computer literacy and word processing
Excellent written and verbal communication skills
Important Details
Schedule: 40 hours weekly
Physical Requirements
Requires full body ranges of motion, manual and finger dexterity, and hand-eye coordination
Requires sitting for long periods of time
Exposure to all patients
' elements including communicable diseases and body fluids
Requires corrective vision and hearing within normal range
Working Environment
Exposure to toxic substances, ionizing radiation, medicinal preparations, and other conditions common to a clinical environment
About the Company
BMC Berkeley Medical Center is part of the West Virginia University Health System and its subsidiaries.
