Director of Quality Assurance

Tohono O•Sells, AZ

5d•Onsite

About The Position

The Director of Quality Assurance is responsible for planning, developing, directing, and evaluating the Tohono O'odham Nation Health Care (TONHC) quality assurance/performance improvement (QAPI) programs and initiatives. The position is based at Sells Hospital in Sells, Arizona, and provides oversight of the QAPI program across Sells Hospital, San Xavier Health Center, Santa Rosa Health Center, and San Simon Health Center. The position may require temporary relocation to other TONHC facilities. The Director directly oversees Infection Control, Safety/Emergency Management, Utilization Review, Compliance, Risk Management, Patient Experience, and Employee Health. The role leads performance improvement and patient advocacy programs, supports compliance with Joint Commission and CMS requirements, monitors care quality and safety, and reports program results and recommendations to TONHC leadership and governing bodies. It also supervises staff, allocates program resources, manages departmental budgets, and provides staff education and technical assistance. Travel may be required as part of work assignments; administrative call may be performed when assigned.

Requirements

Master's degree in Health Care Administration, Nursing, or Business Administration.
Degree or diploma from a professional nursing program approved by the legally designated state-accrediting agency when the applicant completed the program.
Four years of experience, education, or training involving quality assurance/performance improvement principles and practices, preparation of technical reports, identification of problem areas, and recommendations for corrective action.
Three years of supervisory experience.
Active, current, unrestricted professional registered nurse license in a U.S. state, the District of Columbia, Puerto Rico, or a U.S. territory.
Current certification in Healthcare CPR and Automated External Defibrillator (AED).
Knowledge of Tohono O'odham culture, customs, and traditions.
Professional knowledge of clinical nursing.
Knowledge of the Tohono O'odham Nation's mission, organization, programs, and health care delivery system, including employee orientation, staff development, and education services.
Knowledge of hospital self-assessment programs and accreditation requirements, including quality assurance, risk management, safety and infection control, utilization review, and Medicare compliance.
Knowledge of governmental and national regulations and standards relevant to regulatory and credentialing organizations, and ability to apply and reconcile requirements.
Knowledge of data collection and analysis techniques, including identifying problems and trends, setting priorities, and recommending resource use.
Ability to use, implement, supervise, and teach electronic data collection appropriately.
Knowledge of hospital functions and departments and the ability to communicate with varied employees and groups to gather information, present recommendations, and coordinate services.
Knowledge of health and educational resources.
Knowledge and skill in using personal computers, software, and related equipment to maintain databases, prepare reports, and track program activities.
Knowledge of HIPAA, Public Law 104-191.
Interpersonal skills and ability to coordinate with medical staff to effect change or meet regulatory requirements.
Knowledge of pathophysiology and advanced understanding of current scientific nursing theories, procedures, and techniques used in patient care.
Ability to recognize deviations from normal and institute health services appropriately and safely.
Ability to travel as required by work assignments.
Upon recommendation for hire, must complete a criminal background check and National FBI fingerprint check, including a 39-month driving record, to determine suitability for employment.
May be required to possess and maintain a valid driver's license, with no DUIs or major traffic citations within the last three years; if required to operate program vehicles, must meet tribal employer insurance requirements for a driver's permit.
Depending on department needs, may be required to demonstrate fluency in both Tohono O'odham and English as a condition of employment.

Responsibilities

Establish, review, and coordinate TONHC performance improvement plans and related interdisciplinary workgroups and teams.
Monitor compliance with Joint Commission and CMS guidelines through reports, committee and department meetings, and reviews of charts, records, and procedures.
Analyze organizational climate and identify employee and patient needs relevant to customer relations and staff satisfaction programs.
Identify system performance measures and actions needed to improve performance, and apply scientific methods to problem-solving.
Investigate and coordinate resolution and follow-up of issues involving quality and appropriateness of patient care.
Conduct tracer methodology reviews and assess the care, treatment, and services provided to patients.
Present formal reports and data, including recommendations, to the Governing Body, TONHC Leadership, Chief Nurse Executive, Leadership Committee, and Medical Staff.
Help ensure health care programs correct deficiencies and make effective use of available resources.
Work with departments to develop and review performance improvement plans and reports, collect data, and support data-driven decisions using performance improvement methods.
Prepare periodic status reports and an annual evaluation of the Hospital's QAPI program for the Leadership Committee and Governing Body.
Provide orientation, in-service training, and technical assistance on QAPI methodologies and requirements; develop and maintain a Performance Improvement/Risk Management resource and information center.
Develop data-tracking mechanisms to identify trends, variances, and care or administrative process failures.
Assess coordination among disciplines and services to support compliance with standards of care, treatment, and services.
Make independent decisions to plan and implement patient-care improvements, coach staff, and support successful changes across the organization.
Initiate, develop, maintain, and evaluate the TONHC Risk Management system to reduce adverse occurrences and potentially compensable events.
Maintain patient complaint logs and ensure timely follow-up and resolution with appropriate staff.
Recommend actions to promote the health and safety of patients, employees, and visitors, and coordinate with QAPI team members.
Monitor and ensure staff development and education regarding risk management processes, including CMS compliance, the Privacy Act, and EMTALA.
Ensure risk management data and documents are handled in accordance with applicable privacy, freedom of information, and patient confidentiality requirements.
Review, coordinate, and report data to the Leadership Team, Performance Improvement Team, and Governing Body.
Chair assigned performance improvement and strategic planning committees and participate in other standing committees as assigned.
Work with the Chief Medical Officer and Compliance Officer to monitor and track tort claims; recommend root cause analyses when appropriate.
Assist medical and nursing staff with mock exercises, including Code Blue exercises, and support related documentation and training.
Ensure substantial compliance with Joint Commission Accreditation Standards across the hospital and three health care centers; conduct audits and use independent judgment to stop services that present a risk to patient care.
Work with clinical and other leaders to support patient and employee needs.
Supervise employees; determine staffing and other resources; establish work schedules and assignments; and communicate work requirements and procedures.
Develop written instructions for complex or non-routine assignments and review proposed changes to functions, procedures, and other matters.
Make decisions on issues not covered by precedents, protocols, or established policies.
Review records, reports, and other data to track progress toward QAPI objectives and goals.
Recommend disciplinary actions and approve, modify, or reject employee career development plans, training requests, utilization proposals, and leave requests.
Support employee development and use available resources to carry out EEO compliance.
Perform administrative call when assigned.
Develop and execute departmental budgets.
Perform other job-related duties as assigned.