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Director of Quality, Risk Management,

3 months ago

Greenwood, Indiana, United States NeuroPsychiatric Hospitals Full time

About Us:
HEALING THE BODY AND MIND.

Founded fifteen (15) years ago, NeuroPsychiatric Hospitals is the largest hospital system in the nation providing care to patients with both neurological and medical needs.


We are unique in that we serve a population which others have been previously been unable to, largely due the patients underlying medial issues.

Our facilities maintain an inter-disciplinary focus using a multi-specialty approach for both neuropsychiatric and complex medical care issues.

This proven approach provides unrivaled quality care for all of our patients.


We have multiple locations throughout the United States and are continuing to add locations to ensure better access to our unique model of care.


Overview:
NeuroPsychiatric Hospitals is looking for a Director of Quality, Risk Management, & Infection Control at our Greenwood, Indiana location. NPH is the national leader in providing medical and neurobehavioral care to patients in acute psychiatric distress.

You will be joining a team of rock star staff who provide exceptional, patient-centered care and understand our patients are always our number one priority


TheDirector of Quality, Risk Management, & Infection Control supports the implementation and monitoring of the quality assurance measurements and audits, and assists in improving patient safety processes throughout the hospital through coordinating and engaging in activities to proactively promote implementation of evidence based best practices and resolve deficiencies.

plans, develops, and directs system infection prevention activities and protocols across NeuroPsychiatric Hospitals; monitors and analyzes the effectiveness of NPHs infection control program acts as the NPH liaison for regional and national infection prevention programs; helps to prepare NPH facilities for surveys and inspections of infection prevention and surveillance measures by accrediting and licensing agencies.

The Clinical Quality and Infection Control Specialist will evaluate quality of patient care and patient outcomes as they relate to healthcare-associated infections; collects, prepares, and analyzes healthcare-associated infection data; presents infection data and makes recommendations for actions; monitors employees compliance in use of barriers and infection prevention measures; prepares and presents educational offerings for the staff; serves as a resource to all departments and personnel.

Benefits of joining NPH as a Director of Quality, Risk Management, & Infection Control
Competitive pay rates
Medical, Dental, and Vision Insurance
NPH 401(k) plan with up to 4% Company match
Employee Assistance Program (EAP) Programs
Generous PTO and Time Off Policy
Special tuition offers through Capella University
Work/life balance with great professional growth opportunities
Employee Discounts through LifeMart

Responsibilities:


Implements and monitors quality and infection control goals and objectives to measure the organizations processes and outcomes while administering programs that focus on improved outcomes of patient care or patient safety.

Interacts with physicians, nurses, department managers, supervisors, and any/all other staff members to provide resource information, and identify new opportunities to improve service and reduce costs.

Generates effectual quality and infection control related policies and procedures for the department and hospital that ensures compliance with JC, OSHA, CDC, CMS and other county, state, and federal regulatory agencies.

Prepares reports, presentations and statistical data that go to the Quality Assurance and Performance Improvement Committee Meetings, Infection Control Committee Meetings, facility's administration and other committees as needed.

Analyzes data to identify trends and resource utilization for use in optimizing compliance.
Assists with the annual assessment of the quality and infection control programs from the prior year activities.

Investigates incidents within the facility and coordinates with the Corporate Compliance to complete the root cause analysis and develop action plans to prevent incidents in the future.

Establish a structure to ensure that patient care activities are addressed in a coordinated manner involving quality improvement and infection control functions.

Collect, analyze and interpret infection-control data and monitors healthcare-associated infections.
Identifies infection control problems and guides corrective action.
Prepares the agenda for the Infection Control Committee meetings and holds regularly scheduled meetings.
Monitors infection control practices and employees compliance.
Initiates and revises infection control policies and procedures.
Conducts outbreak investigation and initiates control measures.
Conduct infection control risk assessments for construction and renovation projects; equipment inspection, and pest control.
Reports communicable diseases to the state as required by law.
Provides educational offerings for orientation and on-going in-services.
Performs mortality reviews in conjunction with the mortality committee and holds regularly scheduled mortality committee meetings.
Submits information to CMS, Press Ganey, etc. as needed.
Ensures all staff receive proper education on new or revised state and/ or federal regulations or Joint Commission standards.
Participates in Multi-disciplinary patient centered case conferences, as appropriate.
Assess and evaluate patients with infections and monitor patient outcomes on an ongoing basis.
Initiates follow-up on employee/patient exposures to communicable diseases.
Oversees employee health from an infection control aspect in conjunction with Human Resources.
Coordinates staff education for infection control as assigned and directed.
Reports information back to the Chief Clinical Officer on a regular and consistent basis.
Participates in root-cause analysis, sentinel events, adverse events and identifies trends as directed by Compliance or Operations. Recommends ways to redesign systems for improvements if needed.
Oversees safety audits.

Establishes/maintains good relationships with COO, CEO and DONs and department leaders to promote a cooperative and constructive environment for improvement.

Promote Quality is everyones business to gain support, understanding and ownership among staff.
Other duties as may be assigned.
Complies with hospital expectations regarding ethical behavior and standards of conduct.
Complies with federal and hospital requirements in the areas of protected health information & patient privacy.

Understands and adheres to NPHs compliance standards as they appear in NPHs Corporate Compliance Policy, Code of Conduct and Conflict of Interest Policy.

Keeps abreast of all pertinent federal, state and hospital regulations, laws and policies as they presently exist and as they change or are modified.

Performs other duties as assigned.

Qualifications:
Registered Nurse or Licensed Practical Nurse or Licensed Vocational Nurse Required, Bachelors degree preferred.

Excellent verbal communication skills necessary in order present quality and infection control reports, provide staff education and to instruct and comfort patients and their families.

Maintain effective contacts with a variety of Hospital Personnel.

Professional knowledge of clinical practice, leadership, performance improvement and research statistics in order to conduct surveillance and prepare related reports at a level normally acquired through the completion of a Bachelors degree from an approved School of Nursing.

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