Under the direct supervision of the Corporate Director of Quality Management and dotted line to the FMC Administrator, this position will oversee the Quality Management Department activities in alignment with the Strategic Goals, Mission and Vision by providing for the following Scopes of Work:

• Performance Improvement: Collection, analysis, data reporting and facilitation of PDSA/LEAN process for assigned Projects and Priority PI Teams
• Regulatory Compliance: Serves as a resource to hospital and medical staff to assure compliance with TJC and other regulatory agency standards
• OPPE/Peer Review: Management of metrics, profiles, and reports of ongoing provider performance and Peer Review; works collaboratively with multidisciplinary departments and physicians
• Quality Projects: Abstraction, analysis, education and recommendations for CMS Core Measure Projects
• Safety: Responsible for the oversight of Midas and patient safety events. Conducts review of cases for Clinical Safety Committee and Root Cause Analysis investigations

1. Collects and prepares data and reports for various committees in an appropriate and meaningful format.
2. Reviews all Opportunities for Improvement (OFI) following core measure abstraction.
3. Prepares annual Performance Improvement Plan
4. Coordinates investigations of clinical quality issues, including Root Cause Analysis consistent with TJC standards and facility policy and maintains documentation of such
5. Serves as the facility’s Joint Commission Coordinator
6. Provides direct oversight of regulatory readiness staff activities
7. Coordinates the Medical Staff process for focused professional practice evaluations (FPPE) and ongoing professional practice evaluations (OPPE).
8. Oversees the hospitals Patient Safety event reporting, data tracking, RCA investigations and follow up actions.
9. Participates in disaster planning, drills & evaluations in collaboration with the Facility Disaster Coordinator

• Assist clinical leaders with ongoing competency assessment, as appropriate to scope of practice.
• Manages departmental budget
• Interviews, selects, hires, and retains employee(s) within the department
• Assists in orientation and training for employees, including other management positions
• Executes progressive discipline up to and including termination
• Manages departmental productivity standards
• Provides strategic leadership for department(s)
• Performs long range planning and overall direction setting at the departmental level
• Responsible for development, implementation and interpretation of system policies within an organization as identified, requested or needed
• Approves payroll and is responsible for accurate payment of employees
• Assures meeting/exceeding of DCH mission and vision and departmental goals

DCH Standards:

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.

• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.

• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.

1. Bachelor’s degree in Nursing required. Master’s degree in nursing, health administration, public health, or business administration preferred. 
2. Minimum of 5 years clinical experience in a hospital setting. Quality Management experience desirable.
3. Proficient in MS office products, MS Outlook, and Internet experience required.
4. Must be able to read, write, and speak and comprehend English.
5. Knowledge of regulatory standards and survey processes preferred

WORKING CONDITIONS

WORK CONTEXT

• Interpersonal relationships:
  • Frequent Physical Contact with others and communication by telephone and/or email.
  • Frequently Lead/Work with other leaders and staff.
  • Deal with external customers.
  • Occasionally deal with Conflict Situations.

• Physical work conditions:
  • Office setting with occasional exposure to patient care units.
  • Offsite travel for meetings.
  • At least quarterly environment of care rounds which may require ladder use to examine above ceilings and entering central plant with exposure to loud noise.
  • Potential for exposure to human body fluids, hazardous conditions, radiation.
  • Potential use of PPE and/or Specialized Hazmat Equipment.

• Structural job characteristics:
  • Frequent timed deadlines for meeting requirements.

PHYSICAL FACTORS

• Ability:
  • Ability of oral and written expression of information to others and ability for oral and written comprehension.
  • Ability to quickly and repeatedly bend, stretch, twist, or reach out with your body, arms, and/or legs.
  • Knowledge in problem solving.

• Activities:
  • Significant use of computer.
  • Average motor coordination, manual and finger dexterity. Ability to push/pull file drawers.
  • Significant degree of sitting, walking and standing.

• Requirements:
  • Light work. Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg controls requires exertion of forces greater than that for sedentary work and the worker sits most of the time, the job is rated for light work.

• Must be able to perform the duties with or without reasonable accommodation.
• Hearing and vision must be normal or corrected to within normal range.
• Physical presence onsite is essential.

OTHER JOB FACTORS

• Deductive Reasoning, Oral & Written Comprehension.
• Adaptability/Flexibility, Dependability, Initiative, Integrity, & Independence