The Director of Quality Management (QM) assumes responsibility and accountability for the hospital-wide Continuous Quality and Performance Improvement program. The Director of QM will assist the CEO/leadership and Medical Staff to establish priorities for Performance Improvement. He/she ensures that disciplines in the hospital work collaboratively to plan and implement Performance Improvement activities. The Director of QM will focus on measuring, analyzing and trending information in order to improve outcomes. He/she will assure ongoing monitoring of performance to ensure that improvements are sustained.The Director of QM will direct and assist in compliance with federal and state regulations and accreditation standards.
Provides leadership and oversight of a comprehensive, efficient and integrated organization wide Continuous Quality Performance Improvement program.
Measures and assesses performance through collection, analyses, and trending of data.
Focuses on processes and systems to improve performance.
Directs, facilitates, and reports on all aspects of services relating to risk management, patient safety, and employee health .
Investigates factors contributing to adverse outcomes in order to improve processes and systems. Encourages reporting on risk reduction strategies in an atmosphere which minimizes blame or retaliation. Fosters environment to reduce unanticipated adverse events and/or outcomes.
Responsible for education of Continuous Quality and Performance Improvement and additional hospital-wide education and training.
Responsible for education of Continuous Quality and Performance Improvement to hospital and medical staff.
Annually reviews hospital wide plans for the functions of CQPI and establishes goals and objectives for the next year.
Acts as a liaison to local health officials and coordinates inspections and accreditation reviews with state and other regulatory agencies.
Other duties as assigned.
Adheres to dress code, appearance is neat and clean.
Maintains regulatory requirements, including all state, federal and Joint Commission regulations.
Maintains and ensures patient confidentiality at all times.
Reports to work on time and as scheduled.
Wears identification while on duty.
Attends departmental inservices and completes annual competencies/education requirements.
Works at maintaining a good rapport and a cooperative working relationship with physicians, departments and staff.
Represents the organization in a positive and professional manner.
Complies with policies and procedures regarding department operations, fire, safety, infection control and emergency management.
Complies with all organizational policies regarding ethical business practices.
Communicates the mission, ethics and goals of the hospital, as well as the focus statement of the department.
Registered Nurse with current licensure in the State of Indiana.
Certification preferred by NAHCQ (National Association of Health Care Quality).
BSN or BS/BA required. Two years of experience in an acute hospital or rehabilitation setting required. Previous supervisory experience preferred.
Demonstrated ability to plan, coordinate, and evaluate PI activities; effective oral and written communication skills and proficiency in basic computer skills required.
Working knowledge of staff development and the educational process, quality improvement, infection control/employee health, and safety/risk management standards.
Effective oral and written communication skills, in English with additional languages preferred; proficiency in basic computer skills required.
Job : Compliance/Quality/Risk Primary Location : IN-Greenwood-Community Rehabilitation Hospital South Organization : 4089 - Community Rehabilitation Hospital South Shift : Day