Manager Quality Management-Quality Management-Full Time

Summary:

The Quality Director has knowledge of JCAHO standards, federal and state regulations.

Responsibilities:

• Reviews and Revises hospital wide policies and procedures to follow the standards set forth by CMS and JCAHO.

• Coordinates the Board's, Medical Staff's, and hospital staff's roles in JCAHO compliance and survey preparation.

• Provides data and analysis reports to the various organizations; local, division, state and group leaders on an ongoing basis, as appropriate.
• Maintains Physicians' awareness of their Quality Management performance on an on-going basis through individual and committee reporting.
• Provides Performance Improvement leadership and consultative services for hospital and medical staff in effectively achieving regulatory accreditation and organizational compliance for Performance Improvement.
• Reports Performance Improvement Data for both the hospital and the medical staff departments to identify trends, establish priorities, and recommend Improvement activities.
• Performs comprehensive concurrent and retrospective review in a timely manner utilizing criteria developed and approved by the medical staff and the hospital.
• Appropriately reports issues found during record reviews to utilization review, infection control, risk management, and other departments as necessary.
• Assists departments and the PI Coordinator in determining their quality management collection, reporting and training needs.
• Assist departments and the PI Coordinator in setting standards for departmental data collection, processing, and reporting internally and externally.
• Act as a change agent and facilitates the change process, to include data analysis, research and development per the direction of the Chief Executive Officer and/or Governing Board.
• Maintains current in JCAHO and regulatory compliance issues.
• Collaborates and integrates Risk Management, Patient Satisfaction, Infection Control, Environment of Care and other hospital wide data into the overall Quality Management program.
• Collaborates with the Medical Staff Coordinator in the collection and reporting of Physician specific data for credentialing purposes.
• Assures integration of the "Patient Safety" program andNational Patient Safety goals with the Quality Management initiative and provides input regarding areas of improvement, as appropriate.
• Coordinates external database data collection and reporting for comparative analysis with the JCAHO and other entities, as appropriate, based upon Medical Records review and other internal data collection.
• Provides identification of and recommendation for staff educational needs related to Quality Management, JCAHO and other regulatory agency compliance.
• Provides recommendations for resolution and changes regarding identified opportunities for organizational improvement.
• Facilitates the Quality Improvement Teams as necessary.
• Provides input, as well as appropriate organizational quality resource management information, analysis and recommendations to formulate sound organizational business plans.
• Serves on the Performance Improvement Council and any other organizational or Medical Staff committees as deemed necessary.
• Abstract charts for Core Measures and enter into the Quantros system.
• Work with Healthstream regarding HCAHPS data
• Identifies and makes recommendations regarding the software and technological advancements needed to enhance data collection and reporting capabilities to support the organization's mission statement.
• Develops and implements policies and procedures for the department.
• Responsible for the recruitment, interviewing and selection of staff utilizing staffing patterns developed for the department.
• Responsible for the completion of performance evaluations for all employees in the department. Returns completed evaluations to Human Resources in a timely manner.
• Recognizes employees' accomplishments, counsels them when needed, and uses disciplinary process when necessary.
• Fosters open communications with other departments by attending committees meetings when appointed, and when necessary working on Performance Issues with other departments.
• /Punctuality.
• Attendance of Hospital mandatory In-services.
• Compliance with Hospital Safety Policies and Procedures.
• Establishes good interpersonal and working relationships with co-workers, employees, patients, and public.
• Respects the rights and privacy of others; holds employee and patient information in confidence.
• Adheres to HIPPA guidelines.
• Actively seeks ways to control costs without compromising patient safety, quality of care or the
• services delivered.
• Demonstrates knowledge of the occurrence reporting system. Uses system to report potential
• patient safety issues.
• Follows established guidelines for reporting a significant medical error or unanticipated outcome
• in the patient's care, which results in patient harm.
• Attends inservice presentations and completes mandatory education week including, but not limited to infection control, patient safety, quality improvement, MSDS and OSHA standards (PPE, First Aid, blood-borne pathogens, hazard communications, emergency procedures and job safety).
• Uses performance improvement plan to improve patient safety.
• Performs all duties and provides care to patients while adhering to the standards of the Patient Safety
• Plan and the National Patient Safety goals.

Job Requirements:

Education/Skills

• Associate Degree in Nursing or in a related field required.

Experience

• Three years of healthcare experience.

Licenses, Registrations, or Certifications

• CPHQ (Certified Professional in Healthcare Quality) within 2 years.
• CPR every two years
• Current RN licensure in State of Louisiana

Work Schedule:

8AM - 5PM Monday-Friday

Work Type:

Full Time