Responsible for the day-to-day management of the organization's quality and safety programs. Develops and manages quality and safety programs exceeding the standards and quality expectations of patients, the Board of Directors, payors, and other relevant entities. Responsible for oversight of nursing services policies, protocols, and educational initiatives. Oversees performance improvement activities, regulatory compliance, and other initiatives that lead to effective clinical resource utilization and improvements in quality. Promotes interdisciplinary collaboration and teamwork to promote excellence in patient centered care. Key customers are clinical practitioners/applicants, physician leaders, and the senior administration team.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor's degree in healthcare related field.

OR

Associate degree in a healthcare field and three (3) years of healthcare supervisory experience.

EXPERIENCE:

1. Three (3) years of relevant healthcare experience.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor's degree in healthcare related field.

EXPERIENCE:

1. Five (5) years of healthcare quality, nursing, education and/or supervisory experience.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Assists in the development and implementation of quality activities and monitors quality indicators for assessment of house wide quality.

2. Develops and implements mechanisms for ongoing data collection, analysis, and reporting of quality indicators.

3. Initiates mechanisms to ensure timely and accurate reporting of data. Relays quality reports to appropriate leadership teams and committees.

4. Develops performance improvement initiatives throughout the institution and supports the impetus for sustained performance improvement.

5. Works in collaboration with the interdisciplinary health care team to support resource utilization and quality improvement, develops educational opportunities for staff, and oversees appropriate policies and protocols for the ambulatory offices.

6. Perform administrative functions for the Quality & Nursing department including, but not limited to, preparation and management of budget, planning, office organization and other management functions.

7. Assist with employee health functions for the organization.

8. Participates in selection and hiring of qualified individuals and evaluates the effectiveness of employees on ongoing basis.

9. Provides ongoing performance reviews that provide objective, constructive feedback regarding strengths and opportunities for improvement, including departmental plans for each employee.

10. Coaches and counsels to correct identified performance deficiencies, developing plans which establish goals, provides follow-up

11. Assists Director with patient incident reports that require root cause analysis or further follow up and implement improvement initiatives to sustain high quality outcomes.

12. Assists Director in developing and monitoring short-term goal setting and long-range plans for the department.

13. Assists with the oversight of quality assurance reports for the ambulatory offices and follows up with offices needing additional assistance with QA programs.

14. Prepares correspondence, reports, forms, policies/protocols, work orders, and specialized documents for the department. Proofreads materials for accuracy, completeness, compliance with departmental policies, formatting, and correct English usage, including grammar, punctuation, and spelling.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Frequent walking, standing, stooping, kneeling, reaching, pushing, pulling, lifting, grasping are necessary body movements utilized in performing duties through the work shift.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Office setting.

2. Hospital setting.

SKILLS AND ABILITIES:

1. Maintains assertiveness and diplomacy skills.

2. Ability to access community and system resources.

3. Good written and verbal skills, along with effective interpersonal communications and negotiation skills.

4. Strong analysis and research skills.

5. Ability to use MS word, excel, access and other software to collect, analyze, and present data.

Additional Job Description:

Scheduled Weekly Hours:
40

Shift:
Day (United States of America)

Exempt/Non-Exempt:
United States of America (Exempt)

Company:
BMC Berkeley Medical Center

Cost Center:
405 UHAE Quality Management

Address:
2500 Hospital Drive

Martinsburg

West Virginia