Director of Quality Assurance

PLEASE NOTE - This position may require temporarily relocation to other TONHC Facilities: Sells Hospital, Santa Rosa Health Center, San Simon Health Center, and San Xavier Health Center.

Position Summary:

Responsible for planning,developing, directing and evaluating theHospital'squality assurance/performanceimprovement(QAPI) programs and initiatives.

ScopeofWork:

This positionislocatedattheTohonoO'odhamNation Health Care (TONHC),SellsHospital,which islocated atSells,Arizona and providesoversight of QAPI program at all fourfacilities;SellsHospital, SanXavier HC,Santa Rosa HC and San Simon HC.Providesdirect oversight and supervision to thefollowingprograms:InfectionControl, Safety/EmergencyManagement,UtilizationReview, Compliance, RiskManagement, Patient Experience and Employee Health.

Essential Duties and Responsibilities:

• Establishes, reviews, and coordinatesPerformanceImprovement(PI) PlansforTohonoO'odhamNation Health Care and relatedinterdisciplinaryworkgroups and teams.
• MonitorsTONHC forcompliance withTheJoint Commission and CMS guidelinesbyreviewing and maintainingreportsbyattendingthevarioushospitalstandingcommitteemeetings and department meetings, andconductsreviews of charts, records, and procedures.
• Analyzestheorganizationalclimate periodically todeterminetheneeds of employees and patients,whichformsthe basis of theinternal and external customerrelationsand staffsatisfaction programs.
• Identifiesmeasures or indicators of systemperformance and the actionsneededtoimproveor correct performance relativetothe goals of Implements scientificrules and methodsto solve problems.
• Identifies, investigates,and coordinates theresolution and follow-up of problemsinvolvingthe quality andappropriateness of patient care.
• Performstracer methodologyreviews as recommended by theJoint Commission through theutilization of nursing skills.
• Reviews and assesses thetype of care,treatment, and servicesprovided to patients and theappropriateness of care.
• Present formalized reports withdatatoGoverning Body,TONHC Leadership,ChiefNurseExecutive, LeadershipCommittee, and Medical Staff memberswith recommendationsrequired by The Joint Commission.
• Takesstepstoensure that health care programs are designed and are administeredinsuch a manner tocorrectdeficiencies and optimally utilize all available resources.
• Workswithalldepartments to assist withdeveloping and reviewingPI plans/reports and data collection.
• Assistsstaff to make data-driven decisions using performance improvement methodologies.
• Prepares periodic statusreportsfor the Hospital'sLeadership Committee and Governing Body toincludean annual evaluation of the effectiveness of theHospital'sQuality Assurance/PerformanceImprovement program.
• Providesorientation,in-servicetraining and technical assistance toeachDepartment on QAPI programmethodologies and requirements.
• Develops and maintainsthe Performance Improvement/RiskManagement resource and information center.
• Developsmechanismsfordata tracking to follow trends,variances, and "fall-outs"inpatient care and administrative processes.
• Assessestheinterrelationshipsamong disciplines and service/programs toensure compliance and competence to enforcethestandards of care, treatment, and servicesprovided by TONHC.
• Exercisesindependent decision-makingprocessesto identify,plan, and execute patient care improvementsthroughout the organization.
• Delivery of successfuloutcomes as a result of goodplanning and execution and spreadschangethroughoutthe organization.
• Works on the frontlineas a coach and mentor in or to achieve and maintainsuccessful changes.
• Initiates, develop,maintains, and evaluatestheTONHC Risk Management system,which reduces adverse occurrencesof potentiallycompensable events.
• Ensures TONHC patientcomplaintslogs are maintained and ensurestimely follow-upwithappropriatestafffor a resolution of the complaint.
• Recommendsappropriateavenues of actiontoensuremaximum health and safety for patients,employees, and visitorsthroughestablished policies,procedures, and coordinatingeffortswithQAPI team members.
• Monitors and ensuresongoingstaffdevelopment and educationregarding Risk Management processes(CMSCompliance,Privacy Act, EMTALA, etc.) are implemented.
• Ensures all data, statistics,reports, and other riskmanagement documents are appropriately governed by thePrivacy of Freedom of Information Acts and differentpatientconfidentialityrules and regulations.
• Review, coordinate and report datatothe Leadership Team, PerformanceImprovement Team, and Governing Body.
• Chairs assigned committeesrelated toperformance improvement and strategicplanning and participate on other standingcommittees as assigned.
• Workswith theChief MedicalOfficerandComplianceOfficer in monitoring and trackingTort claims.
• Recommends root causeanalyseswhen appropriate.
• Assistsmedical and nursingstaff inconducting mockexercises,including Code Blue exercises using nursingskills and assists withdocumentationandtraining.
• Ensures TONHC toinclude the hospital and the three (3) health care centerssubstantiallycomply withthe Joint Commission Accreditation Standards.
• Conductsaudits to ensurecompliancewith The Joint CommissionStandardsand uses independent judgmenttoceaseservicesifit presents a risk to patient care.
• Worksin concertwithkeyclinical and other Leadershipstaff toensure patientandemployee of employees.
• Supervisethework of employees.
• ImplementsoverallQualityAssurance/PerformanceImprovement Plan and PatientAdvocacy programs and plansaccordinglytosatisfy the hospital's varying requirements, priorities, and objectives.
• Determinesstaff and otherresourcesnecessary for program operations and makesadjustmentsamongsubordinate units asdeemed appropriate.
• Establishes or approvesoverallworkschedulesand determinesindividual and group work assignments.
• Conducts meetingsandconferenceswithsubordinatestaff toexplainworkrequirements, methods, and procedures.
• Formulatesand issueswritteninstructions and proceduresfor non-routine and complex assignments.
• Reviews, modifies,approves, or rejectschanges in functions,procedures, and other mattersproposedby subordinates.
• Makesdecisions on problems not coveredby precedents,protocols, or established policies.
• Reviews and analyzesrecords,reports, and other datato trackthedepartment's progress in achieving QAPIobjectivesand goals.
• Recommendsdisciplinary actionsinvolvingsupervised employees.
• Approves, modifies, or rejectscareerdevelopment plans, trainingrequests,employeeutilization proposals, and related personnel.Approves or disapproves all leaverequestsfor employee supervised.
• Demonstrates sensitivity to thedevelopment needsof all employees; seeks out and utilizesall available resourcesin carrying out the EEO compliance.
• PerformsAdministrative Callwhen assigned.
• Develops and executesdepartmental budgets.
• Other job-related duties assigned.

Knowledge,Skills, and Abilities:

• Knowledge of the TohonoO'odhamculture,customs, and traditions.
• Professional knowledge in clinical nursingispertinentto hold this position.
• Knowledge of theTohonoO'odham Nation's mission, organization,programs, and requirements of a healthcaredelivery system tocoordinate and interfacethe Employee Orientation, Staff Development, and EducationServices Programswith all departments of theHospital and meetthe need of management and employees.
• Knowledge of hospitalself-assessment programs,accreditation requirements,including qualityassurance,riskmanagement, safety/infection control, utilizationreview, and Medicare compliance.
• Knowledge of governmental and nationwide regulations and standards,whichdeal withthevariousregulatoryandcredentialing groups, and an abilityto apply and reconcilerequirementsin preparingrecommendations and in coordinating this program.
• Knowledge of data analysis and collectiontechniquesto collect and analyze data,identify problems and trends, establish priorities on majorissues, make recommendations on utilizingappropriate resources.
• Must have knowledgeand abilityto appropriatelyutilize,implement, supervise,andteachthe use of electronicdata collection.
• Knowledge of thevariousfunctions/departmentswithin theHospital and motivations of varied employeesandgroups to effectivelycommunicate witheachothertogather information,present recommendations, and coordinate program services.
• Knowledge of health and educational resources.
• Knowledge of and skill in using personalcomputers, varioussoftware, and relatedcomputerequipment isrequired tomaintaindatabases, prepare reports, and trackprogram activities.
• Knowledge of HealthInsurance Portability and Accountability Act of 1996,Public Law 104-191 (HIPAA).
• Knowledge of interpersonal skills and ability toestablish coordinationwith themedicalstaff toeffectchange or meet regulatory requirementsfor TONHC.
• Knowledge of pathophysiology of disease entities. Advanced understanding of current scientific nursing theories, procedures, and techniques usedinthe care and treatment of all types of patients.
• Knowledgeand ability torecognizedeviationfrom the normal to institutehealth servicesappropriatelyand safely.
• Ability to travel as requiredwithin the course of work assignments.

MinimumQualifications:

• Master'sDegree in Health Care Administration,Nursing or Business Administration and;
• Degree or diplomafrom a professional nursing program approved by thelegallydesignated State-accrediting agency at the time theapplicantcompleted theprogram and;
• Four years of experience, education, or training, involvingprinciples,techniques, and accepted practices of quality assurance/performance improvement workpreparation of technicalreportsregardingqualityassurance/performanceimprovementissues, identifyingspecific problem areas and providesrecommendationsfor correctiveactionand;
• Three yearsofsupervisory experience.

Licenses,Certifications, SpecialRequirements:

• Must haveactive,current, and unrestrictedlicense as a professional registered nurse in a State,District of Columbia,theCommonwealth of Puerto Rico, or a territory of the UnitedStates and;
• Must have currentcertification in HealthcareCardio Pulmonary Resuscitation (CPR),AutomatedExternalDefibrillator (AED).
• Upon recommendation forhire, a criminalbackground and a National FBIfingerprintcheck are requiredtodetermine suitability foremployment, including a 39-month driving record.
• May requirepossessing and maintaining a valid driver'slicense (no DUIs or major traffic citationswithin the last three years).
• If required,mustmeet theTohonoO'odhamNationtribalemployer'sinsurancerequirementsto receive a driver'spermit to operate program vehicles.
• Based on the department'sneeds,incumbentsmay be required to demonstratefluency in both theTohono O'odham language and English as a condition of employment.

PhysicalDemands:

While performing theduties of this job, theemployee is regularlyrequired totalk or hear.The employee is frequentlyrequiredto sit; walk;use handstofinger,handle, or feel,reach with hands and arms.The employee must occasionally lift and move up to 30 pounds.

This list of duties and responsibilitiesisillustrativeonly of thetasks performed bythisposition and is notall-inclusive.