Under the general supervision of the chief of the division, the Director of Quality implements and directs activities that support the Gov. Juan Luis Hospital’s quality and safety program to drive overall performance excellence and consistent performance of best practice in the maintenance of accreditation and licensure requirements. The Director of Quality serves as a key support to the senior leader for the department in driving the initiatives and responsibilities of the Quality Management department. Serves as an internal mentor and resource in health care quality and performance improvement. Coordinates activities of the hospital’s QAPI program to ensure conformance with regulatory and accreditation standards. Oversees implementation of quality measures and core measure abstraction.

1. Plans, designs, coordinate, and direct the assigned components of the hospital’s quality and safety program.
2. Coordinates the activities of the hospital’s Quality and Safety Committee and serves as key stakeholder of the Quality and Safety Committee.
3. Develop the annual performance improvement plan for the organization and utilize appropriate methods for collection and analysis of data.
4. Develops the annual data inventory, data collection plans and implements quality and performance measures.
5. Supervises the concurrent review, core measure abstraction and retrospective clinical analyses to determine trends of nonconformance.
6. Assesses organization-wide compliance with accreditation standards and regulations in collaboration with leadership and staff. Identifies areas of vulnerability and directs strategies to enhance compliance,
7. Identify problematic areas in the delivery of care and facilitate performance improvements groups to improve those areas.
8. Facilitates assigned performance improvement activities.
9. Oversees the activities of the Policy Committee to ensure that the organization maintains current policies and procedures which are in compliance with regulatory standards.
10. Develops and manages the hospital continuous survey readiness program to maintain a state of continuous survey readiness and functions as a lead resource in coordinating regulatory and accreditation surveys.
11. Acts as a liaison between the Quality & Performance Improvement department, related medical staff committees and hospital departments.
12. Provides guidance and assistance to the performance improvement teams and department heads in their performance improvement activities.
13. Organizes and participates in scheduled environmental and clinical rounds to evaluate the organization’s compliance with organizational policies and other regulatory standards.
14. Identifies trends, and educational needs for staff based on monthly reviews.
15. Develops annual education requirements for staff training on performance improvement.
16. Delivers quality and performance improvement presentations during new employee and annual orientation.
17. Develops performance improvement projects for continuous improvement of the hospital’s quality and safety program using standard performance improvement methodologies.
18. Works with the Nursing leadership, Medical staff leadership and clinical managers to implement and monitor the annual quality and PI plan, as well the use of clinical process, outcome and patient satisfaction data to guide oversight and development of remediation and improvement activities.
19. Prepares monthly and quarterly reports as directed for submission to the Board of Directors.
20. Develops and supervises all assigned staff in the department.
21. Attends required standing committee meetings of the hospital as well as other committees with a direct linkage to quality and safety.
22. Enhances professional growth, maintains licensure/ certification requirements and stays current on quality and performance improvement industry trends by ongoing participation in continuing education requirements.
23. Performs other assigned duties and responsibilities as delegated by management.