GENERAL SUMMARY OF POSITION

Manages quality assessment and improvement activities, regulatory compliance, staff education and competency for assigned clinical area. Collaborates with physicians, nurses, and other members of the health care team to review, collect, analyze, and use data that reflects the performance of the organization and its services. Provides direction, support and education in performance assessment, maintenance, and improvement.

EDUCATION

• Bachelor’s degree and/or licensing in a Rehabilitation specialty; knowledge of program development, program evaluation, and accreditation procedures required and
• Master’s degree preferred

EXPERIENCE

• 3 years administrative or supervisory experience in a rehabilitation or healthcare setting. required

KNOWLEDGE, SKILLS, AND ABILITIES

• Knowledge of accreditation, safety, and regulatory requirements.
• Ability to utilize technical and support operations.
• Working knowledge of word processing, spreadsheet, and database software applications.
• Excellent verbal and written communication skills.
  This position has a hiring range of $72,758 - $130,041

• Contributes to the effective management of the department. Establishes and meets annual goals that are developed to assist the department achieving its vision and mission. Attends and actively participates in appropriate and/or assigned department and/or hospitals committees as evidence by meeting minutes. Interacts effectively with leaders, subordinates, and peers to accomplish the goals of the department.
• Maintains quality assurance policies and procedures in compliance with all regulatory agencies. Assures that the department plan aligns with the hospital plan. Maintains and monitors operating statistics.
• Manages quality assurance activities. Coordinates development, education and monitoring of quality assurance protocols related to department procedures. Coordinates Q.A. audits and reports for department, hospital, and corporate Q.A. committees. Continuously instructs and educates department staff on the necessity of properly completing incident reports on a timely basis.
• Directs the department’s quality assurance activities. Audits/monitors all systems which impact the quality of department outcomes or service. Develops new processes to improve system performance within allotted resources. Assists in training and implementing performance improvement initiatives. Coordinates an effective communication system for system improvement notices or reminders.
• Collects and provides statistical data for hospital related projects. Conducts and documents medical record reviews. Assists in performance assessments and improvement activities on a departmental and/or hospital-wide basis.
• Collects data and provides reports to medical staff departments according to established time frames.
• Collects, aggregates, displays, and conducts first level analysis of data obtained from monitoring and assessing the quality of patient care.
• Educates the medical staff and other health care providers on proper documentation of rendered services.
• Enhances professional growth and development through participation in educational programs, current literature, in-service meetings, and workshops. Assists in performance assessments and improvement activities on a departmental and/or hospital-wide basis.
• Evaluates progress on effectiveness of performance assessment, maintenance, and improvement.
• Facilitates and supports performance improvement teams to improve processes and outcomes.
• Gathers and analyzes data. Makes recommendations in collaboration with other health care professionals.
• Integrates the patient care delivery system including medical, nursing and support services.
• Interacts with medical support staff and/or hospital quality review committees to facilitate the recognition, research, isolation, and resolution of potential of problems for assigned case load.
• Participates in meetings and on committees and represents the department and hospital in community outreach efforts as required. Performs other duties as assigned.
• Provides staff support to medical staff departmental meetings as assigned. Participates in meetings and on committees and represents the department and business unit in community outreach efforts.
• Coordinates accreditation activities to ensure adherence to accreditation and regulatory standards. Coordinates CAP accreditation activities including ongoing compliance with CAP standards and preparation for CAP interim and on-site inspections. Ensures ongoing compliance with CLIA 1988 laboratory regulations and the State of Maryland. Coordinates State of Maryland/CMS regulatory activities and preparation of on-site inspections. Coordinates TJC accreditation activities including ongoing compliance with TJC general and laboratory standards and preparation for TJC surveys. Coordinates required responses to the above-mentioned agencies and any other requests regarding licensure, accreditation, exception responses, plan of correction, etc. Ensures the information is complete, accurate and timely. Manages Laboratory’s 24/7 inspection readiness program. Works closely with the medical director, supervisors, pathologists and administrative director to ensure 100% inspection readiness. Provides periodic management report to pathologists prioritizing top 10 QA/QC radar screen priorities. Documents progress made on these priorities.
• Maintains and manages the laboratory occurrence data. Assists staff with identifying indicators, setting thresholds, and implementing performance improvement. Organizes reviews and monitors the Proficiency Survey Testing Program. Evaluates departmental corrective action plans when proficiency survey testing results are unacceptable and responds to Proficiency Testing organizations (ex. CAP) and State of Maryland inquiries. Directs development, revision, maintenance and yearly documented view of technical policy and procedure manuals. Assure that policy and procedures are written in CLSI or other designated format and comply with Federal Standards.
• Manages Laboratory Occurrence reporting program. Coordinates all follow up activities, identifying systematic errors/trends and initiates corrective action to eliminate these errors/trends. On a monthly basis, reports on reported incident trends by pre-analytical, analytical & post-analytical occurrence. Serves as departmental resource and expert on risk management.