Director of Quality/Performance Improvement

2 weeks ago

Tuba City, Arizona, United States Tuba City Regional Health Care Corp. Full time

Navajo Preference Employment Act :


In accordance with Navajo Nation and federal law, TCRHCC has implemented an Affirmative Action Plan pursuant to the Navajo Preference in Employment Act.


Pursuant to this Plan and corresponding TCRHCC Policy, applicants who meet the necessary qualifications for this position and (1) are enrolled members of the Navajo Nation, Hopi Tribe, or San Juan Southern Paiute Tribe will be given preference in hiring and employment for this position, (2) are legally married to enrolled members of the Navajo Nation, Hopi Tribe, or San Juan Southern Paiute Tribe and meet residency requirements will be given secondary preference, and (3) are enrolled members of other federally-recognized American Indian Tribes will be given tertiary preference.


Overview:

POSITION SUMMARY

This position is responsible for directing, plans, and organizes the staff and activities of the quality management/ performance improvement program to achieve approved clinical goals and strategic operating plans and objectives.

A performance improvement program will evaluate performance in the organization and develops and implements measures to improve it. Ensures compliance with regulatory agencies in accordance with internal and external requirements/regulations.

Directs departments and is fully accountable for monitoring program activities, including compliance, planning, implementing, and evaluating program development to ensure clinical and financial activities in decrease waste and adding value to the organizations overall financial stability and resources.


Qualifications:

NECESSARY QUALIFICATIONS

Education:
Bachelors degree in Nursing. Must obtain masters degree in Nursing within 2 years of hire.

License/Certification:
Certification from an accredited Lean Program for a Lean yellow belt.

Must obtain black belt within 1 year of hire.
Must obtain masters black belt within 2 years of hire.

A valid, current, full and unrestricted Professional Nursing License to practice nursing in any state of the United States of America, The Commonwealth of Puerto Rico, or a territory of the United States
Must maintain a current valid certification of the following throughout employment:

Basic Life Support (BLS) from the American Heart Association

Experience:


Five (5) years of supervisory experience in quality and performance improvement in an acute-care health care setting or related healthcare clinical leadership.


Other Skills and Abilities:


A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers.

All employment references must address and indicate success in each one of the following areas:
Accessing community resources for patient referrals
Knowledge of diagnosis related groups (DRG) and documentation requirements
Positive working relationships with others
Possession of high ethical standards and no history of complaints
Reliable and dependable; reports to work as scheduled without excessive absences
Ability to sense varying skill levels and direct instruction accordingly
Detail oriented, well organized, and applies critical thinking, reasoning, deduction, and inference skills
Knowledge of report writing, graphical analysis, and working with computer spreadsheets and database programs
Completion of and above-satisfactory scores on all job interviews, demonstrating to the satisfaction of the interviewees and TCRHCC that the applicant can perform the essential functions of the job
Successful completion of and positive results from all background and reference checks, including positive employment references from authorized representatives of past and current employers demonstrating to the satisfaction of TCRHCC a record of satisfactory performance and that the applicant can perform the essential functions of the job
Successful completion of fingerprint clearance requirements, physical examinations, and other screenings indicating that the applicant is qualified to be employed by TCRHCC and demonstrating to the satisfaction of TCRHCC that the applicant can perform the essential functions of the job

Submission of all required employment-related documents, applications, resumes, references, and other required information free of false, misleading or incomplete information, as determined by TCRHCC.


MENTAL AND PHYSICAL EFFORT
The physical and mental demands described here are representative of those that must be met by an

employee to successfully perform the essential functions of this job.

Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Physical:


This position requires an individual of high energy who can maintain a long and flexible schedule to meet the management requirements.

The physical requirements include; sitting at a desk for long periods of time, long periods of sitting in meetings; frequent sitting for intense work on a personal computer, frequent walking to interact with staff within the facility, frequent bending, kneeling, crouching, twisting, maintaining balance and reaching.

Must be able to hear, speak and comprehend over the telephone and in person with others. Must have ability to lift, push and pull up to 50lbs frequently.

Sensory requirements for position include prolonged ability for far, near, and color vision, depth perception, seeing fine details, hearing normal speech, telephone use and ability to frequently hear overhead pages.

Must have ability of both hand manipulation in simple and firm grasping, fine manipulation, and use of keyboard.

Mental:
Uses independent judgment and analytical skills to make decisions that impact operations, finances, and customer service within the organization.


The incumbent must have the ability to perform in structured and unstructured environments and possess a keen attention to detail and propose practices/mechanisms to enhance customer satisfaction.

Must have ability to continually concentrate, handle a high degree of flexibility, handle multiple priorities in stressful situation, demonstrate high degree of patience, adapt to shift work, work in areas that are close in crowded, frequently cope with high levels of stress, make decisions under high pressure, work alone, and occasionally cope with anger/fear/hostility of others in a calm way and manage altercations.


Environment:


May frequently be exposed to chemical agents, extremes in temperature of humidity, occasional exposure to infectious diseases, dust, fumes, gases, hazardous or moving equipment, and loud noises.


Responsibilities:

ESSENTIAL FUNCTIONS:
Management of the quality and performance improvement programs, ensuring quality of care and patient comes are reduced to zero.

Directing quality management activities which will include performance improvement, quality review, Joint Commission readiness, data collection and reporting, and core measures management.

Establishing policies and procedures as needed.
Performs other assigned duties as needed.
Provides leadership for system-wide development and implementation of the QI Plan in all domains of quality
including patient safety and care processes in accordance with the mission and vision of CDP.
Develops a system for defining, identifying, monitoring, and analyzing departmental quality indicators.
Reviews departmental indicators on a regular basis and makes recommendations as needed to ensure quality improvement efforts are effective.
Identifies trends, prioritizes, and directs others in implementing recommended improvements.
Ensures compliance with state and federal regulations pertaining to patient safety and quality improvement.
Manages the data systems for patient satisfaction, producing and interpreting reports toward improvement of patient access and satisfaction.
Reports quarterly and annual hospital quality data as required by state and federal regulations.
Conducts quality improvement meetings and provides direction and education to all staff.

Ensures the execution and communication of performance improvement activities throughout the organization by directing others in the implementation and communication of their performance improvement activities and reporting results to the CEO and/or Board as appropriate.

Provides direction and participates in processes for establishing and implementing policies and procedures to address patient safety and quality of care.

Facilitates and/or advises internal QI project teams and QI measures.
Gathers and reports quality data to the following federal and state databases on a monthly, quarterly, and annual basis: Hospital Improvement Innovation Network (HIIN), National Health Safety Network (NHSN),
Quality Net, Centers for Medicare/Medicaid Services Abstraction and Reporting Tools
Supports and assists PI colleagues and on-site teams with data collection, reporting, interpretation, and analysis for their PI Projects. Functions as an facilitator, consultant, and/or project manager, as required.

Ensures high quality of both the process and results of the work, and that appropriate change management principals are applied in the areas impacted by change.

Manages relationships with PI leaders and key stakeholders to effectively transition responsibilities to operational partners and drive a culture of continuous improvement and data-driven decision making.

Skilled in working with operational, financial and clinical data from disparate sources, including EMR, payroll, general ledger, and hospital inpatient/outpatient data and process improvement.

Lead facility-wide standardization in targeted process improvement initiatives and evaluate success through pre-established criteria and measurement tools. Support division-wide standardization of process improvement initiatives through facility adoption and implementation.
Facilitate and/or lead clinical process improvement teams as needed to achieve quality and performance improvement goals.
Ensure proper PPE is always worn while on duty including but not limited to, face mask, gloves, gown, isolation gown, NIOSH-approved N95 filtering facepiece respirator or higher, if available), and eye or face shield.
Complete all donning and doffing tasks in a safe acceptable method and discard of used PPE accordingly. (see CDC website for most current updates)

Complete task training for all routine cleaning and decontamination processes for all surfaces contaminated by a communicable disease to ensure a high level of patient, visitor, employee and external customer satisfaction.

Performs other duties as assigned.

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