Under the direction of the Patient Quality Services Executive Director, the Director of Patient Quality, Accreditation, Infection Prevention and Associate Health provides operational leadership for the organization's quality improvement, accreditation, regulatory compliance, infection prevention/associate health and performance improvement programs. This position is responsible for coordinating activities that promote high-quality patient care, regulatory readiness, organizational performance excellence, and compliance with federal state, and accrediting body requirements for HaysMed.
The Director collaborates with physicians, nursing leadership, department directors, and frontline staff to implement initiatives that improve patient outcomes, enhance safety, reduce risk, and support organizational strategic goals.
JOB REQUIREMENTSMinimum Education Required- Master's degree in nursing.
Experience Required- Minimum of three years of healthcare quality, patient safety, accreditation, regulatory compliance, infection prevention, associate health or performance improvement experience.
- Minimum of three years of progressive leadership or supervisory experience.
- Experience leading multidisciplinary performance improvement initiatives.
Preferred Experience- Experience with DNV accreditation standards and ISO-based quality management systems.
- Experience with CMS Quality Reporting Programs and commercial pay-for-performance initiatives.
- Experience utilizing quality analytics and healthcare performance dashboards.
- Experience in infection control and prevention in a healthcare setting.
- Experience in associate health program in a healthcare setting.
Certifications- Current registered nurse licensure in the State of Kansas or has work permit from the State Board of Nursing.
- Professional certification in one of the following: healthcare quality, patient safety, accreditation, infection prevention or associate health. If not held at hire, professional certification is required within three years.
ESSENTIAL FUNCTIONSQuality and Performance Improvement- Directs day-to-day operations of the organization's quality management and performance improvement programs.
- Leads organization-wide quality initiatives designed to improve clinical outcomes, patient experience, operational effectiveness, and regulatory compliance.
- Facilitates the use of evidence-based improvement methodologies, including Lean, Six Sigma, PDSA, Root Cause Analysis, and Failure Mode and Effects Analysis.
- Monitors key performance indicators and quality metrics and develop action plans to address opportunities for improvement.
- Oversee quality dashboards and reporting mechanisms for executive leadership, medical staff, committees, and governing bodies.
Accreditation and Regulatory Compliance- Coordinates continuous accreditation readiness activities.
- Leads organizational compliance with DNV, CMS, state, and other regulatory requirements.
- Cross trained to support the duties of the Stroke Coordinator.
- Oversee development, implementation, monitoring, and follow-up of corrective action plans related to accreditation findings and regulatory reviews.
- Partners with leaders throughout the organization to ensure ongoing compliance with standards of care and regulatory requirements.
- Serves as a subject matter expert regarding accreditation and regulatory standards.
Patient Safety and Risk Reduction- Promotes a culture of safety, transparency, accountability, and continuous improvement.
- Collaborates with Risk Management, Infection Prevention, Associate Health, and operational leaders to address patient safety concerns.
Infection Prevention & Associate Health- Directs the day-to-day operations of infection prevention program.
- Directors the day-to-day operations of the associate health program.
- Leads organization-wide quality initiatives designed to improve hospital acquired infections and exposures.
- Monitors key performance indicators and quality metrics and develop action plans to address opportunities for improvement around infection prevention and associate health.
- Overseas, quality dashboards and reporting mechanisms for executive leadership, medical staff, committees, and governing bodies.
- Cross trained to support the duties of the infection control/associate health nurse.
Quality Reporting- Oversees collection, validation, submission, and monitoring of required quality reporting programs.
- Directs CMS hospital quality reporting activities, including inpatient and outpatient quality measures.
- Oversees abstraction, performance analysis, and submission of clinical quality measures.
- Monitors commercial pay-for-performance programs and quality incentive initiatives.
- Ensures reporting deadlines and data integrity requirements are met.
Leadership and Personnel Management- Provides leadership, direction, mentoring, and professional development to assigned staff.
- Conducts recruitment, orientation, evaluation, coaching, and performance management activities.
- Establishes departmental goals aligned with organizational strategic priorities.
- Promotes teamwork, accountability, customer service, and effective communication.
- Fosters collaborative relationships with medical staff, administration, and department leaders.
Financial Management- Participates in development and management of departmental budgets.
- Monitors resource utilization and operational efficiency.
- Identifies opportunities to improve performance while maintaining fiscal responsibility.
Policy and Program Management- Oversee development, review, implementation, and maintenance of policies, procedures, and work instructions related to quality, accreditation, infection prevention and associate health.
- Ensures policies remain current with regulatory and accreditation requirements.
- Supports organizational preparedness for surveys, audits, and inspections.
RESPONSIBILITIES- Maintains confidentiality of protected health information in accordance with HIPAA guidelines.
- Participates in organizational committees, task forces, and leadership teams as assigned.
- Maintains knowledge of current healthcare quality, safety, accreditation, regulatory trends and infection prevention and associate health requirements.
- Performs other duties as assigned by the Patient Quality Services Executive Director.
HIPAA: This position will have access to the following Protected Health Information in order to carry out the duties related to their position at Hays Medical Center based on the following criteria:
Primary-required (routine) to do the job:
Secondary-required for the job, but mostly be exception; and
None-no approved access
Description of Information
Primary:
Patient Demographic Information (information used to identify a person): Name, Date of Birth, Address, Race, Marital Status and Religion.
Clinical Information (information that describes a patient's health status): Diagnosis, Reports/Medical Notes, Test Results, Problem List, Procedures, History and Physical.
Coding Information (clinical information that is in (alpha) numeric format: ICD-9 Codes, Revenue Codes and CPT Codes.
Financial Information/Insurance (information related to insurance, billing and payment): Billing Information, Payer Name, Payer ID, Account Balances, Plan Elements Covered, Payment Information and Payment Rates.
Functional DemandsInfection Control: Initial and Ongoing training in dealing with infection control. Trainings could include but are not limited to blood borne pathogens, bodily fluids and bio hazardous materials as it applies to your daily work environment.
Patient Interaction: Rarely
