Director of Quality

Position Summary :

The Director of Quality (D-Q) is responsible for establishing a corporate quality management system and team that promotes excellent quality of care and that positively impacts the financial performance of Conway Medical Center (CMC). The D-Q or assigned department representative attends all hospital committee meetings where committee activities and responsibilities involve the organization’s Quality Management System (QMS).

Qualifications : Education :

Bachelor’s Degree in Nursing or comparable clinical field required.

Master’s Degree in Health Care Administration or closely related field preferred.

Experience

A minimum of five (5) years’ acute hospital care experience required.

2 years of leadership at a Director / Administrative level preferred.

5 years of Quality / Accreditation / Risk experience required.

2 years of experience with physician practice Quality preferred.

Prior experience with external facing quality metrics reporting organizations such as Leapfrog, CMS Star Ratings, CMS Pay for Performance and etc. required.

Prior experience in working under the following programs and standards preferred :

• DNVGL NIAHO standards;

ISO 9001, etc.

Licensure / Certification / Registration

Duties & Responsibilities :

Serve as a resource for the organization regarding quality activities. Such activities include organization change management, assisting with accreditation and regulatory compliance, assisting with risk management support functions, assisting with patient satisfaction data support functions, process design and redesign, education, and use of quality principles and tools.

Direct the process of monitoring, measuring, and assessment of QMS processes to achieve desired results which are appropriate, timely, cost-effective, efficient, and safe.

Provide oversight for the hospital Quality Assessment / Performance Improvement (QAPI) program, including development, review, revision, implementation.

Assist in development and implementation of QAPI plans and processes for individual services including hospital-owned physician practices.

Coordinate and manage abstraction, aggregation, analysis, and reporting activities for the CMS IQR / OQR and other externally facing quality programs, as well as assisting with clinical registries required for accredited and / or certified programs of the hospital.

Facilitate PI teams as requested, facilitate planning sessions as requested, and assist with facility-wide compliance with accreditation and other regulatory requirements.

Responsible for departmental payroll, budgets, education, schedules, supplies, policies, procedures, and job descriptions.

Greet all patients and their accompanying family members when applicable and provide exemplary customer service.

Work effectively and collaboratively with colleagues, physicians, and department heads.

Effectively utilize strong organizational skills.

Consistently display effective verbal communication skills.

Proficient understanding and use of technology / PC skills required.

Regularly exercise independent judgement.

Complete other duties as assigned by department leadership.

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