Director - Quality

Directs the operational, financial management and personnel resources for Quality Performance, Accreditation / Licensing, Patient Relations, Infection Prevention, Policy and Procedure Process Management, Patient Safety utilizing an Enterprise / Systems approach.

Disseminates information for the enterprise-wide quality program. Coordinates various certification, patient safety and regulatory programs, via delegation and oversight.

The Director of Quality Management reports directly to the Chief Nursing Officer with a dotted line reporting structure to the CEO (or equivalent) and to The Board of Directors.

Participates directly in Leadership and Board meetings, representing the enterprise-wide Quality Department and its associated functions.

This position participates in state and national networks, professional organizations, and conferences in the service of promoting healthcare quality within the organization and for the community, on an ongoing basis.

This is a safety sensitive position

Wage Scale : $$

Essential Functions

• Develop operations, positions, budget and assignments to assure coordination of all assigned , oversee and coordinate activities in legal issues, quality improvement activities, risk management and infection control.
• Plan and evaluate multidisciplinary process improvements relating to quality of clinical care / practice / service.
• Assist medical staff, clinical and non-clinical departments with performance improvement activities.
• Serve as internal consultant for Joint Commission and other regulatory requirements, process improvement, and licensed provider OPPE / FPPE Medical Staff processes.
• Facilitate and monitor the performance improvement process throughout the organization and provides support and education as it relates to the performance improvement plan.
• Direct performance improvement processes and aggregation of results to assist in PSQC Committee, MEC, Executive Leadership, and The Board of Directors with information necessary to assess and evaluate services and resource needs, including regulatory and legal issues.
• Develops and implements data analytics work team to oversee required data reporting and annual selection of metrics that evolve from the Strategic Plan, Quality Dashboard, and regulatory requirements.
• Oversight responsibility for all the regulatory body surveys, Department of Health, CMS, etc.
• Advises Trios Health Leadership on the selection of accrediting body (Joint Commission, DNV, HFAP, etc.)
• Direct the development of and monitoring of Infection Control functions for the Hospital.
• Provide or delegate consultation for the Cancer Care, Stroke, Stemi, OB-SCOAP, and SCOAP programs.
• Oversee ongoing maintenance for the Quality / SharePoint site; with technical assistance from
• Receive and manage information on occurrences and near misses; reviews and analyze for potential liability; provide and / or coordinates investigation and follow-up of serious occurrences and sentinel events with participation at the level appropriate to the event.
• Provides training and coaching to Directors, Managers, and Supervisors on how to conduct Root Cause Analysis (RCA), so as to develop a pool of competent employees who can conduct and complete RCAs with oversight by the Director of Quality.
• Works closely with Human Resources (HR) and Trios Health Leadership so as to help establish and sustain a Just Culture disciplinary approach which supports maximal reporting of incident and near misses Recommends and facilitates change in the organization to improve patient safety.
• Leads initiatives to develop proactive risk assessment strategies across services to identify and mitigate patient safety risks.

Leads in development of a mechanism for internal communication of patient safety issues.

• Monitors patient and family satisfaction. Responds to questions and complaints from patients, family members, and payors regarding care.
• Participates in discharge planning including coordinating patient transfers to other facilities and coordinating community resources.

Provides discharge education and resource referrals to patients.

Performs chart review to identify actual or potential issues with service delivery, patient outcomes and satisfaction, compliance, cost, and reimbursement.

Qualifications and requirements

• Bachelor's degree in nursing
• Master's degree in nursing - Preferred

Benefits :

Medical Insurance : PPO, HRA, HDHP offered through Blue Cross Blue Shield

Dental Insurance : Offered through Delta Dental

Vision Insurance : Offered through VSP

Free EAP (Employee Assistance Program)

Paid Time Off (Up to days a year or hours)

Employer Paid Short-Term and Long-Term Disability

Coverage options for Medical, Dental and Vision include : Employee, Employee & Spouse / Domestic Partner, Employee & Child, Family

Voluntary Benefits :

Health Savings Account

Flex Spending Account : Medical & Dependent

Voluntary Life : including Employee, Spouse / Domestic Partner, and Child

Critical Illness : including Employee & Spouse / Domestic Partner

Hospital Indemnity

About our Health System

Trios is a -bed hospital located in Kennewick, WA, and is part of , a diversified healthcare delivery network committed to making communities healthier with acute care, rehabilitation, and behavioral health facilities from coast to coast.

From your first day to your next career milestone your experience matters.

EEOC Statement

Trios is an Equal Opportunity Employer. Trios is committed to Equal Employment Opportunity for all applicants and employees and complies with all applicable laws prohibiting discrimination and harassment in employment.