Director Quality Management

Position Summary :

Responsible for the overall program of utilization and patient safety. This includes the Hospital wide Performance Improvement Program, Risk Management Program including Infection Control, Patient Satisfaction Survey, Joint Commission (TJC) Survey Coordination and Patient Safety.

Serves as the facility Corporate Compliance Officer and HIPAA Privacy Officer. Performs all work with accord to the mission, vision, and values of St.

Mary’s Regional Medical Center.

Employee has responsibility to lead health equity process reviews, analysis, and reporting, including creation of tactics and action plans to address / improve health equity as data determines.

• Employee has authority on behalf of the C-Suite and BOG to focus on health equity.
• Employee is responsible for reporting of data trends and analyses to the c-suite and BOG to ensure communication and knowledge of health equity improvement opportunities.
• Employee serves as the point of contact for action plans to improve health equity, with the C-Suite championing improvement initiatives.
• Employee will present health equity program performance and actions for improvement to the C-Suite and BOG at a predetermined basis of semi-annually at a minimum.

Job Duties / Responsibilities :

Works closely with senior leadership to formulate process improvement activities, risk reduction strategies and enforce compliance measures related to Federal and State standards.

Serves as resource to resolve complex issues and serves as liaison to corporate risk and compliance departments. Serves as Administrator on Call with other senior leaders.

Puts safety first for employees; ensures compliance with OSHA, Infection Control and Environment of Care requirements. Provides training to staff.

Measured by knowledge of staff through safety rounds and workers’ compensation claims, etc.

• Responsible for complying with St. Mary’s hiring procedure and ensures that interviews are completed timely. Measured by vacancy rate and time-to-fill position.
• Provides timely feedback to new hires through the 90-day evaluation. Provides intermittent feedback to staff on performance along with annual performance evaluations.

Measured by 100% complete timely.

Assesses current staff educational needs. Develops structures and processes within Surgical Services to improve employee knowledge, skills and abilities.

Utilizes best practices to positively impact Staff education and competencies. Measured through competency documentation and education plan.

Requirements :

• Bachelor’s degree in Nursing, Healthcare Management or Business Administration required, masters preferred.
• Registered Nurse licensure in the State of Oklahoma required.
• A minimum of five (5) years management experience with a focus on quality improvement leadership required.
• Clinical nursing experience preferred.
• Previous experience with TJC standards and regulatory compliance of other agencies required.
• Experience in risk management and healthcare compliance principles required.
• Certification in one of the following : Certified Professional in Healthcare Quality, or Certified Professional in Risk Management strongly preferred.
1 day ago