The Director, Quality and Patient Safety plans, develops, implements and manages comprehensive and effective systems to monitor and evaluate the quality and appropriateness of patient services and programs in support of the organizational mission and goals. This position will work closely under the supervision of the Hospital CEO, functions as a support person in the coordination and organization of administrative processes in a high quality efficient and cost-effective manner. All duties to be done in accordance with Joint Commission, Federal and State regulations, Oceans' Mission, policies and procedures and quality standards.
Essential Functions: - Works with VP, Quality and Patient Safety implementing organization-wide quality programs at the hospital level.
- Facilitates the hospital Quality Assessment and Performance Improvement (QAPI) committee.
- Prepares an annual evaluation of the hospital QAPI plan, including process and outcomes.
- Oversees hospital-wide performance improvement (PI) projects identified through on-going data driven quality assessment.
- Coordinates the hospital's data collection procedures and provides on-going support and education to staff regarding QAPI tools and reporting requirements; utilizes data and collaborates with leadership to set priorities and provide guidance in their development of quality improvement work plans.
- Serves as a resource to the medical staff, administrators and other staff including participation in root cause analyses, as indicated, to investigate potentially avoidable sentinel events.
- Completes assignments accurately, in a timely manner and within procedural guidelines.
- Coordinates education for QAPI principles and regulatory standards as indicated. Conducts training for staff.
- Participates in Joint Commission Accreditation process including plan of action tracking and completion.
- Performs other duties and projects as assigned by the facility administrator and corporate office.
Requirements
Education / Experience: - Associate degree or RN diploma required.
- Healthcare experience related to clinical leadership and/or quality assessment and performance improvement.
- Behavioral health experience preferred.
Qualifications / Skills: - Demonstrates proficient computer skills with MS office products and electronic QAPI software solutions.
- Ability to create and provide training programs on related quality performance topics.
- Ability to work with minimal supervision and simultaneously manage multiple projects.
- Knowledge of state and federal regulatory requirements, Joint Commission Accreditation.
- CPHQ certification preferred.
- Must successfully complete CPR certification and an Oceans approved behavioral health de-escalation program.
Work Environment: Subject to many interruptions. Occasional pressure due to multiple calls and inquiries. This position can be high paced and stressful; must be able to cope mentally and physically to atmosphere. Work requires spending approximately 90% or more of the time inside a building that offers protection from weather conditions but not necessarily from temperature changes.
