Director of Performance Improvement/Quality Assurance

Coshocton Regional Medical Center•Coshocton, OH

1d•Onsite

About The Position

The position is for a Director of Performance Improvement/Infection Prevention RN in the Quality Assurance Department at Coshocton Regional Medical Center. This 56-bed, not-for-profit hospital serves East Central Ohio, providing 24-hour emergency services and acute care, including hospital-based physician clinics. Coshocton Regional Medical Center is an Accredited Chest Pain and Heart Failure Center and holds The Joint Commission's Gold Seal of Approval®. The role involves developing, managing, and integrating comprehensive Performance Improvement (PI) and Infection Control (IC) Programs to achieve high standards in quality, efficiency, safety, satisfaction, and value with transparency. The Director will oversee both programs, focusing on improving performance, maintaining scorecards, conducting clinical assessments, and ensuring continuous survey readiness and compliance with regulatory standards.

Requirements

Bachelors Degree required, preferably in a healthcare related field.
State RN licensure or a License in healthcare field preferred.
5–7 years healthcare experience.
2-6 years quality improvement experience.
Current BLS (AHA) certificate upon hire and maintain current.
Certification in Infection Control (CIC) within 36 months of hire.
Experience in reviewing charts for quality care issues.
Detail oriented organizational skills.
Must be able to handle multiple cases, directions and follow-through.
Good communication skills both verbally and written.
Experience with Medical Staff communication.
Coordination of internal departments and external entities to ensure compliance with company policies, and state/federal regulatory and accreditation standards.

Nice To Haves

Masters Degree preferred.
Desired expertise in microbiology, antibiotic usage, and clinical practices.
Team facilitation and experience with hospital accreditation standards and survey process preferred.
Knowledge of local regulatory standards & OSHA regulations a plus.
Certified professional in healthcare quality preferred.

Responsibilities

Develop, manage, and integrate a comprehensive Performance Improvement (PI) Program and Infection Control (IC) Program.
Develop and share best practices for improving performance in quality, safety, perception of care, value, and efficiency.
Develop and maintain scorecards for all Service Lines, defining expected outcomes and benchmarks based on Quality, Safety, Satisfaction, and Value.
Complete Clinical Assessment, Diagnosis, and Treatment for the Service Lines.
Coordinate and manage hospital-wide performance improvement activities, including continued survey readiness.
Oversee on-going publicly reported quality initiatives such as Core Measures and Patient Satisfaction.
Work collaboratively with Administration and Leadership.
Ensure execution and communication of Performance Improvement and Patient Safety activities from the department level to the Board of Trustees.
Supervise, assess, plan, implement, and evaluate hospital surveillance, prevention, and control of infection management.
Assist with policy and procedure development and implementation, maintaining compliance with CDC, OSHA, TJC or AOA HFAP/DHS/CMS, and other regulatory agency directives.
Act as a primary education consultant to hospital employees, physicians, patients, volunteers, and visitors in safe Infection Control/Prevention practices.
Coordinate all hospital infection control activities and interventions with the Infection Control Committee, Pharmacy & Therapeutics Committee, Medical Staff, and hospital employees.
Respond to potential exposures by communicating with patients, physicians, and regulatory agencies, and assisting Employee Health to communicate with employees.
Collaborate with the Employee Health Nurse and assist in coordinating the hospital employee health program.
Perform safety rounds of the physical plant to ensure basic Infection Control/Prevention and safety practices are adhered to in all hospital departments.
Create collaborative customer relationships.
Plan appropriate group processes.
Create and sustain a participatory environment.
Guide groups to appropriate and useful outcomes.
Build and maintain professional knowledge.
Employ evidence-based practice.
Integrate best research with expertise and patient values for optimal care.
Work in interdisciplinary teams.
Apply performance improvement and infection control methodologies to minimize waste, decrease errors, increase efficiency, and improve care.
Utilize informatics appropriately to communicate and manage knowledge with clinical expertise and patient values for optimal care.