Director of Quality

4 weeks ago

Lexington, United States Lexington Regional Health Center Full time
Job DescriptionJob DescriptionDescription:

Lexington Regional Health Center
Title: Director of Quality

Effective Date: July 22, 2024

Supervisor: Chief Executive Officer

Department: Administration

FLSA Status: Exempt

Principle duties and responsibilities

  1. Develops, implements, communicates and maintains the facility’s Quality Management Plan.
  2. Leads policy review committee ensuring hospital policy system is up to date meeting regulatory and accreditation standards.
  3. Monitors and assists in the Internal Audit committee’s quarterly meetings to ensure staff are educated to meet quality standards.
  4. Leads the annual Critical Access Hospital (CAH) Review with the Heartland Health Alliance. Prepares the CAH Review report in preparation for the review visit and reports resulting recommendations, including action items, to the Administrative Team.
  5. Leads the quality discussion with the annual accrediting body on-site review.
  6. Assists with the Medicare Beneficiary Quality Improvement Project (MBQIP) and The Merit-Based Incentive Payment System (MIPS) initiatives and requirements.
  7. Supports departments with use of “Electronic Health Record Learning Journeys” to increase departmental success and quality.
  8. Leads the quality report for the “Get with the Guidelines” related to the Americal Heart Association.
  9. Reports on the Emergency Department (ED) provider response times internally and to ED professional vendor.
  10. Supports the effectiveness of the contract review program and process.
  11. Monitors and validates Centers for Medicare and Medicaid Services (CMS) and Department of Health and Human Services (DHHS) requirements for quality reporting through the Nebraska Hospital Association to ensure accurate information is being reported, and process improvements are being developed and implemented to maximize hospital results.
  12. Develops agenda for hospital board sub-quality monthly meeting.
  13. Assists in developing and implementing goals, objectives, policies, procedures, monitoring systems and assessment methods pertaining to all quality initiatives in all departments/service areas. Also, manages monthly quality indicator meetings. Coordinates the development, approval, monitoring and progress of all department/service areas’ yearly Quality Indicators following the Plan, Do, Check Act, Stop cycle. Maintains the Quality Indicator Reporting Dashboard for reference by all staff and leadership. Prepares reports concerning the Hospital Quality Indicator Program and the hospital wide quality management activities for Administration. Performs an annual survey of the Quality Indicator Program and presents results to Administration.
  14. Educates the organization’s leaders, concerning the approaches and methods of quality management as well as their responsibilities to the program as organizational leaders.
  15. Educates department managers and other discipline coordinators in the approaches and methods of the quality management process and acts as their consultant in such matters.
  16. Monitors quality performance by gathering relevant data and producing statistical reports.
  17. Ascertains that data gathering efforts are valid, reliable and comprehensive and substantiates that findings from data analysis are reasonably related to the data assessed.
  18. Determines that improvement actions taken are appropriate to the performance assessment data and analysis, including follow-up.
  19. Establishes communication mechanisms to ensure that performance assessment and improvement results from the quality management activities are channeled to all appropriate individuals, departments or committees.
  20. Manages systems to ensure the confidentiality of all data resulting from quality management activities.
  21. Coordinates the development, approval, monitoring, and progress of Lexington Regional Health Center’s Internal Audit Program. Maintains the Internal Audit Reporting Dashboard for reference by all staff and leadership.
  22. Annually reviews and revises the following facility policies and procedures: a. Organizational Plan of Care and List of Services (requires approval of Board) b. Quality Indicator Program (requires approval of Board).
  23. Maintains and provides current resource information to assure that all the components of the quality management activities are functioning properly and in an effective manner.
  24. Participates in ongoing quality management educational opportunities, workshops and meetings as appropriate.
  25. Enhances professional growth and development through participation in educational programs, current literature, in-service meetings, and workshops.
  26. Participates in patient care activities that could include blood exposure and risk to bloodborne pathogens (eg: lacerations, handling of blood-contaminated specimens, etc.)
  27. Maintains patient and staff safety through the use of patient safety tools (TeamSTEPPS, Just Culture, etc.)
  28. Regular attendance at the assigned work location is required.
  29. Performs all other duties as assigned.

Minimum knowledge, skills, and abilities

  1. Ability to develop, enter data and utilize data analysis tools in various computer systems as is typically acquired through the completion of a Bachelor's degree in Business Administration, Nursing or a related field preferred.
  2. Certified Professional in Healthcare Quality (CPHQ) preferred; or, if not certified, required to have 15 hours of continuing education units in healthcare quality annually. The CPHQ certification must be maintained.
  3. A minimum of two years’ experience in healthcare quality preferred.
  4. Ability to maintain strict confidentiality with regard to protected and sensitive information.
  5. Ability to complete reports and correspondence at a professional level.
  6. Ability to immediately respond to common inquiries and complaints from patients, employees and regulatory agencies in collaboration with supervisor and administration.
  7. Advanced written and oral communication skills necessary to converse in an effective and positive manner with individuals from diverse backgrounds, including: patients, hospital employees, providers, visitors and the community.
  8. Successful completion of required knowledge and training of standard precaution and transmission protocols and when to apply during principle duties and responsibilities.

Working conditions

  1. Works in a normal office work environment, with little exposure to excessive noise, dust, temperature, etc.
  2. Spends 90% of work time sitting to complete computer/paper work at a desk and time at meetings. The other 10% of work time is spent going to and from meetings and gathering information, ambulating up to 500 feet at a time to go to various meetings. Required to transport a laptop or other small materials of minimal weights for use at meetings to display information for others for meetings.
  3. Direct exposure to body substances during patient care activities and on contaminated surfaces such as patient equipment.

Management responsibilities

1. None

Job description statements are intended to describe the general nature and level of work being performed by employees assigned to this job title. They are not intended to be a complete list of all responsibilities, duties and skills required.

Requirements:


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