director of quality

Job Details
Job Location:    Main Hospital Campus Headquarters - Madison, WV
Position Type:    Full Time
Salary Range:    Undisclosed

Description

Summary

The Director of Quality is responsible for planning, developing, and directing quality assurance policies, programs, and initiatives. Performs data abstraction, data entry, and data collection to support clinical performance measures, particularly those related to MBQIP, QPP, WVHA Initiatives (EQIC), and NHSN. Information is analyzed and files are maintained and prepared for internal use, committee, or department requests. Continuous efforts to provide more effective and efficient care to patients.

Boone Memorial Health's culture is rooted in being patient-focused and performance-driven. The Director ensures that patient expectations are consistently exceeded while maintaining the highest level of customer satisfaction through effective public relations. This role also supports compliance with CMS, Joint Commission, OSHA, and CDC standards, ensuring quality care and a safe environment for all patients.

 

Essential Functions

Reasonable accommodations may be made to enable individuals with disabilities to perform these essential functions.

Clinical Quality:

• Lead the development and execution of the organization's quality assurance and performance improvement strategies.
• Collaborate with senior leadership to align quality initiatives with organizational goals and objectives.
• Establish short-term and long-term goals for quality improvement and performance monitoring.
• Promote a culture of quality and continuous improvement across all levels of the organization.
• Monitor and evaluate key performance metrics, and benchmarks to ensure consistent quality outcomes
• Lead and drive performance improvement projects aimed at enhancing operational efficiency, reducing costs, and improving service quality.
• Identify opportunities for process improvement through data analysis, root cause analysis, and stakeholder feedback.
• Facilitate cross-functional teams to implement PI initiatives and monitor progress to ensure sustainable improvements.
• Provide training, support, and guidance to staff on continuous improvement tools.
• Oversee the collection, analysis, and interpretation of data related to quality assurance and performance improvement efforts.
• Prepare and present regular reports on quality metrics, PI initiatives, and outcomes to senior leadership, regulatory bodies, and other stakeholders.
• Use data to identify trends, forecast performance gaps, and inform decision-making processes.
• Reports core measures and other reporting measures deemed per different entities such as RWHC, MBQIP, etc and others as assigned and applicable for CAH.
• Ensure that the organization complies with all relevant healthcare regulations, industry standards, and accreditation requirements (e.g. TJC & CMS).
• Maintains and develops Policy & Procedures in areas of responsibility as assigned.
• Works with administrative and nursing staff to improve efficiency, safety and quality of care for all patients.

Competencies

• Certification in Infection Control
• Annual Paycom Learning Education/In-services
• MIPS training

Supervisory Responsibilities

• Supervises and actively participates in abstraction of quality indicators, data reporting, and performance improvement.

Physical demands

• Ability to perform various motor skills such as; standing for long periods of time, walking, lifting (up to 50 pounds) using proper lifting techniques, stair climbing, reaching, bending, twisting, pushing, pulling, squatting, grasping and arm-hand coordination on a continuous basis.

Travel required

• None

Education and experience

• Requires a current RN license with BSN preferred, or Masters in Public Health (MPH),
• or Certified Medical Technologist, or a bachelor's degree in Microbiology or Epidemiology.
• Must have a minimum of five years clinical experience in a hospital setting or disease surveillance experience in a public health setting.
• Demonstrated leadership and customer service experience
• Computer skills

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Equal Employment Opportunity Policy Statement

Boone Memorial Hospital, Inc. provides equal employment opportunities to all personnel and applicants for employment and prohibits discrimination, harassment, prejudice, or behavior of any type based on race, color, religion, age, sex (including pregnancy), national origin, disability status, family medical history or genetic information, past or present military service, sexual orientation, gender identity or expression, family or parental status, political affiliation, or any other characteristic protected by federal, state or local laws.

Qualifications

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