Quality Director

About This Role

This Quality Director role is responsible for the program development, implementation, and management of quality improvement initiatives, risk management, corporate compliance, patient safety, and patient experience activities throughout the hospital district. The director engages the organization to improve quality performance and communicates all quality activities to medical staff, the Board of Directors, administration, and staff. This position is responsible for gathering and reporting quality data to outside quality improvement organizations, and coordinates, investigates, and responds to customer complaints and patient-related issues.

Responsibilities

• Prepare for and coordinate regulatory surveys
• Respond to regulatory surveys and ensure compliance
• Conduct regulatory self-reporting activities and follow-up
• Review Quality Review Reports and follow-up on findings
• Investigate and report on Failure Mode and Effect Analysis and Root Cause Analysis
• Investigate and follow up on complaints
• Manage patient satisfaction surveys
• Oversee the Beta HEART program
• Oversee the Service Excellence Initiative
• Participate in the Continuous Quality Improvement Program Committee
• Participate in the Nurse Advisory and Regulatory Compliance Committee
• Participate in the Board of Directors Quality Committee
• Prepare for Peer Review charts and participate in the committee
• Participate in the Medication Error Reduction Program Committee
• Participate in the Falls Committee
• Participate in the Wound Care Committee
• Participate in the Fire, Life, Safety/Emergency Operations Committee
• Conduct Team Walk Rounds
• Participate in the Beta HEART Steering Committee
• Participate in the Service Excellence Council
• Participate in the CHA Certification and Licensing Committee
• Participate in the Medical Executive Committee
• Participate in the Infection Control Committee
• Participate in the Medi-Tech Clinical Systems Optimization Committee
• Participate in the Patient & Family Advisory Council
• Participate in the Corporate Compliance Committee
• Manage Emergency Department Transfer Communication data
• Manage Departmental Quality Dashboards
• Manage Patient Experience Surveys
• Manage MBQIP, NHSN, HQR (IQR, OQR), eCQMs, TJC DDSP data
• Manage Dexur – IQR, OQR, SIERA files
• Manage HQIP – IQR, OQR data
• Manage Survey Solutions
• Conduct Ongoing Professional Practice Evaluation