Location : Mary Immaculate Hospital and Southampton Medical Center
The Quality Director is responsible for overseeing and administering the quality and performance improvement program and its functions which include but are not limited to safety, accreditation, infection prevention, and peer review for the facility, off-site departments, and additional areas as designated.
Essential Job Functions
Provides leadership for the development and implementation of the facility-wide quality and performance improvement plan and functions.
Facilitates and supports the development and maintenance of a robust quality infrastructure to meet system quality objectives and regulatory standards.
- Collaborates and acts as a resource to the facility and medical staff in the analysis and submission of data for evaluation to ensure compliance with accreditation and regulatory agencies, CMS Conditions of Participation, and payor requirements.
- Collaborates with the clinicians, administration, medical staff, and department / services to assist in coordination, standardization, development of outcomes measures and continuity of quality improvement initiatives.
- Facilitates the collection, aggregation, and analysis of quality indicator data to provide a basis for internal and external benchmarking.
- Collaborates with the medical staff and organizational leadership to ensure review and improvement for quality issues through the peer review process and Ongoing Professional Practice Evaluation
- Collaborates with the system and regional leadership to develop quality and patient safety initiatives designed to improve patient outcomes and eliminate harm.
Identifies areas of potential risk and participates in organization-wide learning.
- Evaluate the effectiveness of current processes and lead the team to strive for continual ongoing improvement.
- Serves as a resource for all internal and external customers for the Quality and performance improvement program and its functions.
- Collaborates with Risk Management, Patient Safety, and High Reliability leads, and Patient advocates to investigate, follow up, and create action plans for Serious Safety and adverse events, and patient complaints and grievances.
REQUIRED :
- 4 year / Bachelor Degree - RN but will consider another clinical degree
- Registered Nurse *will consider another clinical license
- CPHQ or obtain within one year of hire.
- MINIMUM of 5 years of Clinical Experience
PREFERRED :
- Graduate Degree (Masters)
- CPHQ or other Quality certification
- Experience in Quality Improvement, accreditation, measurement
- Experience in tools related to Operational Excellence such as PDSA
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