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- Marinette, WI 54143
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Director of Quality - AMC - BA
Bay Area Medical Center • Marinette, WI
Posted 6 days ago
TITLE: Director of Quality - Aurora Medical Center - Bay Area
Reports to: Vice President of Nursing
Supervises: Clinical Data Manager, Infection Preventionalist
Primary Purpose: Plans, organizes and directs the overall administration and management of quality and care management programs. Accountable for achieving the targets established for budget, productivity, quality, patient loyalty, and staff engagement. Major Responsibilities:
Responsible for the development and implementation of the quality and care management programs, policies, and procedures that describe how they will support patient care, facilities, employees, and the community.
Provides support and consultation to the governing body, management, medical staff, committees, and clinical areas to plan, promote, facilitate, and conduct quality assessment and improvement and performance improvement activities.
Implements care management and quality programs to accomplish targets and provide measurements related to care management strategy. Leads the communication and project management of all care management efforts and initiatives.
Coordinates Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) Steering Committee and acts as the 'expert resource' regarding Joint Commission, peer review organizations, and other regulatory requirements. Disseminates information as necessary and may collaborate with other peers in this process.
Directs the process for facilitating root cause analysis which includes assigning staff, ensuring the correct participants, overseeing scheduling, and overseeing timely completion of all required paperwork. Supports risk management in the analysis of events and submits reports to JCAHO when required.
Directs the facilitation and implementation of all quality and care management initiatives (e.g. Centers for Medicare & Medicaid Services, Premier).
Participates in and directs State and Federal surveys and national projects around safety and quality.
Reports on quality and safety efforts. Develops and reports on the governance/leadership dashboard, including the significant and sentinel events.
Responsible for the short and long range planning, developing, and innovating of the areas under his/her management. This includes providing direction to the department heads to ensure the goals and objectives of the departments are in conjunction with the goals and objectives of the site and system.
Responsible for interpreting and enforcing all Medical Center policies and procedures as they relate to his/her staff as well as developing functional policies and procedures to ensure the smooth operation of departments under his/her management.
Performs human resources responsibilities for staff which include interviewing and selection of new employees, promotions, staff development, performance evaluations, compensation changes, resolution of employee concerns, corrective actions, terminations, and overall employee morale.
Develops and recommends operating and capital budgets and controls expenditures within approved budget objectives.
Responsible for understanding and adhering to the Aurora Health Care Code of Ethical Conduct and for ensuring that personal actions, and the actions of employees supervised, comply with the policies, regulations and laws applicable to Aurora's business.
Licensure, Registration and/or Certification Required:
Bachelor's Degree in Quality Management or related field.
Typically requires 7 years of experience in quality improvement and assessment. Includes 3 years of management experience in management of staff, budgets and quality functions for a large hospital or health care organization.
Knowledge, Skills & Abilities Required:
Advanced knowledge of the JCAHO and/or National Committee for Quality Assurance (NCQA) regulations and standards.
Advanced knowledge of quality improvement methodologies (e.g. Lean, Six Sigma, Juran, etc.).
Advanced clinical knowledge of care processes in a tertiary care setting.
Excellent analytical and statistical skills along with proficiency with MS Office.
Excellent facilitation, verbal and written communication skills.
Ability to function in a fast-paced, matrix management environment.
Physical Requirements and Working Conditions:
Generally exposed to a normal office environment.
Operates all equipment necessary to perform the job.
This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.