Director of Quality Management
The Director of Quality Management is responsible for the management of efficient, cost effective operations of the performance improvement functions for the assigned Post Acute Medical hospital(s). Coordination with hospital and medical staff leadership to foster a culture of safety by coordinating the design, measurement, assessment, and planning activities to improve patient care and organization functions. Serves as a liaison with accrediting and regulatory bodies such as TJC, CMS, and Department of Health. Provides direction and assistance to the medical staff regarding medical staff quality measures. Performs other related duties as assigned or requested. This is an exempt position.
Quality and Risk Management
• Monitors adherence to compliance for assigned hospital(s) and reports to the Hospital CEO and Chief Quality Officer as appropriate.
• Develops and/or maintains reporting systems to provide timely information to administration regarding compliance status with guidelines, rules/regulations and internal policies and procedures. Works with staff so that a systematic process for monitoring and reporting is timely and appropriate
• Maintains knowledge of state, federal, and local laws and regulations that impact hospital/clinic operations. Demonstrates a working knowledge of accreditation requirements, especially TJC. Works to ensure the readiness of hospital /clinic for accreditation surveys and other compliance inspections. Develops and maintains systems for ensuring compliance with laws, rules, regulations and accreditation requirements.
• Systematically performs on-site surveillance inspections with the Safety Office and Infection Control personnel in the hospital for the purpose of validating compliance with codes and standards.
• Coordinates implementation of the hospital’s performance/outcomes improvement plan, consistent with system-wide QAPI plans
• Collects, analyzes, evaluates, and appropriately reports data relative to performance improvement for inpatient and outpatient facilities throughout the region. Notes trends as they appear and makes appropriate recommendations when opportunities to improve patient care arise. Regularly reports to administration, assigned committees, locally and at the corporate level.
• Serves as chairman for the hospital QAPI committee. Assures all minutes and reports of assigned committees are complete and available in a timely manner.
• Serves as a resource to QAPI teams and department managers in performance improvement process techniques and external agency standards. Facilitates QAPI team meetings, when appropriate, and ensures timely follow-up and reporting.
• Serves as hospital representative to corporate QAPI Committee and provides other related support as required. Attends meetings and provides input relative to area of expertise.
• Manages the occurrence monitoring system and ensures timely investigation of incidents to minimize risk to the hospital; keeps Corporate Risk Manager appraised of significant issues in the facilities assigned.
• Serves as co-chair of the Environment of Care (EOC) committees.
• Prepares agenda and minutes for meetings, to include QAPI, MEC, Governing Board.
• Responsible for the overall data collection and score card compliance.
• Annually reviews / evaluates policies and QAPI plan in conjunction with corporate office.
• Responsible for completing the intracycle monitoring process.
• Responsible for restraint education
• Facilitates the development of the post survey Plan of Correction.
• Manages the patient satisfaction program; assures that patient complaints are heard and acted upon in a timely fashion to maximize satisfaction and minimize risk.
Medical Staff QAPI Resource
• Serves as resource to hospital’s medical staff on compliance and performance/outcomes improvement activities.
• Assists medical staff in development of compliance and QAPI monitors. Makes recommendations to the Medical Executive Committee and to other appropriate medical staff committees.
• Provides input for the Medical Staff and Medical Executive Committee meetings. Coordinates staff input and follow-up for all items of committee business. Ensures recommendations are communicated and actions are recorded in committee minutes
• Conducts periodic compliance reviews of applications for medical staff privileges, ensuring completeness and compliance with standards such as Medical Staff Bylaws, TJC, and Medicare.
• Collects data for the ongoing professional practice evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) of medical staff.
Education and Training: Licensed as a Registered Nurse in the state where the hospital resides. Current BLS certification required.
Experience: Minimum of three to five years current clinical experience required. Prior quality management experience preferred.
Knowledge, Skills, and Abilities:
• Ability to effectively express ideas and views when speaking to groups, hospital managers and staff, and patients/family members.
• Clerical ability to write reports, memorandums, etc.
• Cognitive ability to gather and analyze data and prepare reports.
• Numerical ability to evaluate statistical data and to make various computations in planning departmental operations and budgets.
• Organizational ability to direct and motivate professional and non-professional staff in performance of all activities.
• Strong leadership and management skills and a high level of initiative for creative problem-solving.
• Capacity to relate to people in a manner to win confidence and establish rapport.
• Organizational skills to prioritize work and use time effectively with flexibility to adjust to changing priorities and the various details of the job.
PAM Health is committed to being the most trusted source for post-acute services in every community it serves by utilizing experienced and dedicated staff to provide high quality patient care and customer service. With over 44 Long Term Acute Care and Rehabilitation hospitals and 16 Outpatient Clinics currently in operation across the country, we are proud to offer services including comprehensive wound care, aquatic therapy, ventilator weaning, amputation treatment, pain management and much more.
Joining our PAMily allows you to work in a collaborative environment with colleagues and leadership with exposure to a variety of patient care levels. Aside from our competitive pay, generous paid benefit time, and excellent insurance options, you will also have opportunities for professional growth through our Education Advancement Program.
We are excited to learn more about you and hope that you consider joining us on a shared mission to improve the lives of others by being an integral part of our We Care Program. Please take a moment to visit us online at [ Link removed ] - Click here to apply to Director of Quality Management | Georgetown Rehab for a comprehensive look at how we're able to positively impact our local communities.
PAM Health does not discriminate and does not permit discrimination, including, without limitation, bullying, abuse or harassment, on the basis of actual or perceived race, color, religion, national origin, ancestry, age, gender, physical or mental disability, sexual orientation, gender identity or expression or HIV status, or based on association with another person on account of that person's actual or perceived race, color, religion, national origin, ancestry, age, gender, physical or mental disability, sexual orientation, gender identity or expression or HIV status.
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