Director - Quality, Patient Safety, And Regulatory

Job Title : Dir Performance Improvement

Job Summary : Develops and ensures implementation of the hospital's quality improvement plan. Plans, directs and manages all functions of the Quality and Performance Improvement Department to include: Medical staff quality and performance improvement initiatives, infection control, and clinical quality improvement activities. Ensures the provision and utilization of data and information to facilitate improvement of performance throughout the hospital. Reports to the Medical Director.

Education :

Work Experience :

Skills Abilities :

Job Function:

Develops and ensures implementation of the hospital's quality improvement plan in accordance with the mission and strategic goals of the organization, regulatory, and accreditation standards. Develops and implements systems, policies, and procedures for the identification, collection and analysis of performance measurement data. Identifies opportunities for improvement and ensures that action plans are implemented. Educates and trains hospital staff regarding quality and performance improvement and initiatives and their responsibilities as related to the hospital's quality improvement plan. Leads, facilitates, and advises internal quality improvement teams. Serves as an educator and consultant regarding measurement tools, data sources, and the development of quality improvement monitoring processes. Facilitates the integration of consistent CQI processes into planning and problem solving throughout the organization. Directs the activities of the Quality Review and Performance Improvement Department. Coordinates medical staff task groups focused on improving specific processes/outcomes related to quality care. Plans and coordinates meeting agenda and data for Quality Coordinating Council and the Quality Operations Committee. Selects, trains/orients and assigns department staff (either directly or through subordinate supervisor). Develops standards of performance, evaluates performance, and initiates or makes recommendations for personnel actions. Develops department goals and objectives, and establishes and implements policies and procedures for department operation. Develops and recommends department operating budget and ensures that department operates within budget. Directs the preparation and maintenance of department reports. Prepares periodic reports for top management, as required. Assures the departments operate according to standards of various accrediting and regulatory agencies. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise. Participates in hospital/medical staff committee meetings as required. Attends and serves on professional/civic service organizations as hospital representative. Performs other duties as assigned or requested.

Functional Demand:

Prolonged periods of standing, walking, or sitting while on duty. Lifting, pushing, and pulling up to 10-15 pounds with or without assistance. Visual and auditory acuity and manual dexterity essential to performing designated duties required. Ability to perform effectively in a stressful and fast paced environment. Ability to pass all required health and other screening tests. Physical conditions are clean, neat and well lit. Maybe subjected to unpleasant sights and odors, stressful situations and hazardous or infectious agents where judgment as to precautions need to be taken is essential. Climate control an ambient temperature variances may be experienced. Exposure to limited amounts of hazardous chemicals or substances and infectious disease processes are a possibility. Hours of duty may be irregular or unexpectedly extended due to emergency circumstances. Direct contact with blood or other body fluids to which universal precautions apply. Personal protective equipment is made available and must be worn.

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