Director Of Quality Services

Job Title: Director of Quality Services

Job Summary: The Director of Quality Services has overall responsibility for administering for enhancing the quality of patient management and satisfaction, to promote continuity of care and cost effectiveness through the integrating and functions of Quality Services, utilization review and management and discharge planning. Responsible for overseeing hospital wide and medical staff quality review processes.

Reports to: CEO

Licensure: Licensed in the State of Arkansas as a Registered Nurse preferred.

Education: Nursing or other clinical healthcare license/degree preferred.

Experience: Three to Five (3-5) years’ hospital experience; experience working with quality services (quality, process improved, or case management) preferred.

Principal Duties and Responsibilities

• Identifies problems and seeks opportunities to improve patient care. Communicates findings to those responsible to affect change.
• Oversees medical staff peer review process, prepares cases for review, facilitates peer review and manages confidential quality files.
• Demonstrates creativity, intelligence and discretion in the planning, organization and coordination of departmental functions.
• Gathers, reviews, assembles and disseminates data to appropriate committees within the Hospital as required.
• Provides back up risk management responsibilities in absence of risk manager.
• Serves as a resource for all Hospital departments/services that relates to Regulatory Compliance.
• Monitors and evaluates the quality, appropriateness and safety of patient care.
• Works closely with Risk Management and communicates to Administrative Team on potentially compensable events identified through event reports and risk event screening.
• Notifies CEO / CNO of Survey Management of any regulatory visits or correspondence.
• Maintains a current copy of State, Federal and other applicable regulatory standards / laws.
• Attends Hospital and medical staff committee meetings as required.
• Oversees Core Measures and Arkansas Inpatient Quality Incentive data abstraction/reporting.
• Provides oversight and assures compliance with regulatory requirements Hospital wide.
• Develops plans of correction for any regulatory survey deficiencies.
• Prepares reports, presents and/or informs the Board and Medical Staff on the hospital’s quality, safety and regulatory performance.
• Works closely with Risk Management in investigation and completion of RCA, Sentinel Event and Serious Safety Event investigations.
• Presents reports to QIC, MEC and Board. Oversees the Quality Improvement Council.
• Coordinates and oversees all TJC and other regulatory survey preparations and assures a constant state of readiness.
• Completes & maintains all TJC applications & correspondence.
• Ensures the ongoing development of the Hospital’s QAPI program and related policies are consistent with regulatory requirements.
• Oversees credentialing functions and assures compliance with data collection for physician Quality Profiles for OPPE, FPPE and reappointment.
• Attends admin team meetings. Reports all regulatory surveys, status of corrective actions and status of facility’s state of survey readiness.