The Director of Quality Management, under the direction of the Regional Chief Quality Officer, will establish, implement, facilitate and coordinate the ongoing, hospital-wide Quality Improvement, Infection Control and Risk Management Programs to assure compliance with TJC, CMS, the state of New Jersey, and other healthcare rules, regulations, and standards in order to enhance the quality and safety of patient care consistent with hospital policies for the adult to geriatric patient, 18 years and over.
· Oversee Quality Management System and implementation of the hospital Performance Improvement Plan.
· Maintain all Quality Improvement plans, policies, procedures and programs. Update and revise as necessary.
· Gather, disseminate and document information on patient care Quality to facilitate compliance with requirements of accrediting and regulatory agencies.
· Coordinate and integrate all Quality Improvement activities within the Hospital.
· Advise and assist medical staff and allied health care personnel in the Quality process.
· Provide an ongoing assessment of the Quality Improvement program.
· Conduct studies and prepare reports and correspondence for patient care evaluation studies; monitor and maintain records.
· Keep appropriate committees informed of changes in accrediting and regulatory standards; maintain a collegial relationship with other hospital department heads to assure coordination, standardization and continuity of Quality Improvement programs.
· Provide in-services on Quality Improvement philosophy, plans, policies, procedures and programs as needed.
· Coordinate concurrent review studies performed within the Quality Improvement Program and prepare resulting reports.
· Maintain tracking systems for reporting data and ensuring that the programs result in quality improvement.
· Keep current with state laws, federal laws and regulatory agency requirements for hospitals regarding all regulations with focus on utilization, quality management, infection control and safety.
· Serve as Hospital Risk Manager and Patient Safety Officer and delegate tasks appropriately.
· Prepare and disseminate reports to Hippocrates, the NJ Patient Safety Reporting Initiative, and the Corporate Service Center as required.
· Collate safety (incident) reporting monthly and report aggregated data and results as required to appropriate committees.
· Collaborate with Regional Chief Quality Officer to identify risk issues or trends and report to Administration and Corporate as appropriate.
· Serve as TJC Liaison.
· Oversight and management of Infection Control (IC) Program.
· Adhere to Hospital attendance policy, as outlined in the Employee Handbook.
· Adhere to all components of the Hospital Compliance Plan in performing job duties and report any violations or suspected violations of the Plan to the Compliance Officer.
· Oversee local compliance activities and collaborate with hospital Compliance Officer (Regional Chief Quality Officer) to ensure that Corporate Compliance Plan is fully enacted and any potential violations are reported through the appropriate channels.
· Demonstrate professional conduct and comply with hospital and departmental policies and procedures.
· Recognize patient abuse and follow policy for making appropriate referrals/interventions.
· Coordinate with host hospital Safety Officer and facilities management to ensure building and hospital safety plans are appropriately updated and implemented.
· Oversee activities of hospital Safety Officer.
· Comply with established Safety and Patient Safety Program practices.
· Perform other duties as assigned or delegated by the Regional Chief Quality Officer, CEO/Administrator, or Chief Operating Officer.
· Limit access to protected health information (PHI) to the information reasonably necessary to do the job and share such information only on a need to know basis for work purposes.
MANDATORY QUALIFICATIONS (SKILLS, EXPERIENCE, EDUCATION)
Registered Nurse with current state license
Bachelor of Science in Nursing or other Healthcare related field
Minimum of five (5) years’ experience as staff nurse or team leader
Previous experience in Quality Management and/or Infection Control in a hospital setting
Formal education and/or documented experience in epidemiological principles, microbiology, patient care practice and infectious diseases
Excellent communication skills
Excellent organizational skills
Ability to work in high stress environment
Ability to speak read and write English
Proficient in the Microsoft Office suite of programs
Management experience preferred
Master of Science in Nursing or other Healthcare related field
CPHQ (Certified Professional in Healthcare Quality) or CPPS (Certified Professional in Patient Safety)
Advanced Proficiency in the Microsoft Office suite of programs
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