CONFIDENTIAL
Manager/Director of Quality Management - Perm

Estimated Pay Range: $92k- $100k 

The Director of Quality Management has responsibility for the quality program for a hospital facility. This includes developing and implementing patient safety initiatives, assuring the success of continuous quality enhancement initiatives inter-and intra-departmentally, developing a proactive risk management program, and overseeing an effective infection prevention and control and employee health program. This role is responsible for appropriately using quality tools (root cause analysis failure mode effects analysis, statistical process control and other statistical methods) to guide process improvement, help problem solve, and benchmark appropriately to ensure a highly reliable organization. The Director ensures compliance with regulatory and accreditation standards and ensures they are continually upheld. The Director will be responsible for the planning, development, implementation, administration evaluation, and continual enhancement of policies procedures, and practices for each functional area. Other duties may be assigned as appropriate.

Required Education

Bachelor’s degree
Or
2-year associate degree with 5 + years of relevant experience in Quality, Risk or Infection Control

Required Experience

• 3-5 years of acute care/hospital experience
• 1 year of Quality experience, prior Director of Quality Management or equivalent is preferred

Required Licensure / Certifications
• Must have an active clinical license such as RN or RT
• CIHQ IC or CIQH-HACP-CMS certification or equivalent OR Commitment to obtain certification within 2 years

Quality & Regulatory
• Works with medical staff and administration to ensure compliance with regulatory agencies
• Manages all clinical quality outcome and performance improvement functions
• Creates and distributes agendas, minutes and quarterly reports related to quality
• Coordinates data collection for studies and management reports
• Analyzes study results in collaboration with Medical Staff to develop follow-up monitoring, and problem-solving actions
• Communicates findings through designated reporting and committee structures
• Ensures follow-up on actions and recommendations made by committees
• Performs investigations and root cause analysis
• Consults and provides input into policy, procedures and standards
• Develops and delivers educational seminars related to performance improvement
• Supervises ongoing and annual program reviews

Risk
• Coordinates all patient safety and risk management activities, including developing and implementing policies and procedures, education, and communication
• Manages Risk Committee meetings and activities
• Manages the hospital Patient Safety Risk Program, including education, reporting, and evaluation of effectiveness

Infection Control
• Plans, develops, implements, and manages the Infection Prevention and Control program
• Coordinates surveillance, recording, investigation, and reporting of data for hospital-associated and community-acquired infections, including admission reviews
• Coordinates concurrent review of nosocomial trends
• Notifies Public Health agency of any reportable disease cases
• Notifies administration and medical staff of unusual infection control situations
• Attends P&T/IC committee meetings, preparing agendas, minutes and providing informational updates to committee members on a timely basis
• Provides staff education, orientation and annual recertifications

Employee Health
• Manages Employee Health Plan and activities
• Ensures appropriate vaccination status and/or declination documents are accurately maintained
• Reviews / clears employees who have been out on sick leave return to work documentations / fitness for duty assessments

Key Competencies (Knowledge, skills, abilities)
• Quality and performance improvement techniques
• Investigation / Root cause analysis skills
• Clinical knowledge, including infection control processes
• Operational knowledge of an acute-care hospital
• Regulatory awareness
• Communication (written and oral) & interpersonal skills
• Training
• Conflict Management
• Confidentiality
• Team leadership

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