REQUIRED EDUCATION AND EXPERIENCE

• Bachelor’s degree in a healthcare-related field or five (5) years of related job or industry experience in lieu of degree.
• Minimum of three (3) years of progressive management responsibility in an acute care setting, one (1) of which is related to managing an organization’s Quality Improvement Program.
• Minimum of two (2) years of clinical, patient care experience or equivalent.
• Experience with quality improvement methodology and data analysis
• Experience developing and implementing clinical, service and operational process improvement initiatives, both small and large scale.

JOB SUMMARY / PURPOSE

Responsible for the implementation and management of the Performance Improvement (PI) plan and maintaining compliance with Joint Commission and relevant State and Federal regulations related to quality monitoring and performance improvement. Oversees the day- to-day operations of the Quality Management staff.

ESSENTIAL KEY JOB RESPONSIBILITIES

• Assists in the design, planning, implementation and coordination of Quality Management, Patient Safety and Performance Improvement activities for the assigned hospital(s) and medical staff departments, committees, divisions, service lines and functions. Proactively coordinates and facilitates performance improvement teams to support key initiatives, including but not limited to, activities focused on clinical quality improvement.
• Participates in an integral role to ensure compliance with CMS HIQRP/HOQRP, TJC, Leapfrog, etc., data collection and reporting of process and outcome measures.
• Maintains current knowledge of accreditation and licensing requirements and must be a resource to staff on these regulations in order to improve management of outcomes and ensure compliance. Assists with regulatory readiness and survey preparation activities including mock survey tracers. Provides consultation and assists physicians, ancillary and nursing departments with regulatory compliance issues. Supports implementation of regulatory initiatives.
• Provides leadership to the Quality Management Department; hires, supervises, and monitors staff performance and productivity. Contributes to the budgeting process.
• Educates and trains staff and physicians in quality improvement including the aggregation and analysis, action planning and reporting of performance data.
• Other duties as assigned by management.
• Reporting Structure may differ in Critical Access Hospitals
  Qualifications