Director of Quality Assurance

Tohono O'odham Nation Healthcare•Sells, AZ

7d•Onsite

About The Position

The Director of Quality Assurance plans, develops, directs, and evaluates the Hospital’s quality assurance/performance improvement (QAPI) programs and initiatives. The position is based at Tohono O’odham Nation Health Care’s Sells Hospital in Sells, Arizona, and oversees the QAPI program across Sells Hospital, San Xavier Health Center, Santa Rosa Health Center, and San Simon Health Center. Temporary relocation to other TONHC facilities may be required. The role provides direct oversight and supervision of Infection Control, Safety/Emergency Management, Utilization Review, Compliance, Risk Management, Patient Experience, and Employee Health. It leads quality and performance improvement work, supports compliance with accreditation and regulatory requirements, oversees risk and patient-complaint processes, and supervises staff and departmental resources. The Director also develops and executes departmental budgets and may perform Administrative Call 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 practices, technical report preparation, identification of problem areas, and recommendations for corrective action.
Three years of supervisory experience.
Active, current, and unrestricted registered professional nurse license in a U.S. state, the District of Columbia, the Commonwealth of Puerto Rico, or a U.S. territory.
Current Healthcare Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) certification.
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.
Knowledge of hospital self-assessment programs and accreditation requirements, including quality assurance, risk management, safety/infection control, utilization review, and Medicare compliance.
Knowledge of governmental and nationwide regulations and standards relevant to regulatory and credentialing groups, and ability to apply and reconcile those requirements.
Knowledge of data collection and analysis techniques, including identifying problems and trends, setting priorities, and recommending appropriate resource use.
Ability to appropriately use, implement, supervise, and teach electronic data collection.
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.
Computer skills, including use of personal computers, software, and related equipment to maintain databases, prepare reports, and track program activities.
Knowledge of HIPAA (Health Insurance Portability and Accountability Act of 1996, Public Law 104-191).
Interpersonal skills and ability to coordinate with medical staff to effect change or meet regulatory requirements.
Knowledge of disease 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 for work assignments.
Criminal background and National FBI fingerprint checks, including a 39-month driving record, are required upon recommendation for hire.
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 the Tohono O’odham Nation tribal employer’s insurance requirements for a driver’s permit.
Depending on departmental needs, may be required to demonstrate fluency in both Tohono O’odham and English as a condition of employment.

Responsibilities

Establish, review, and coordinate performance improvement plans and related interdisciplinary workgroups and teams.
Monitor compliance with The Joint Commission and CMS guidelines through reports, committee and department meetings, and reviews of charts, records, and procedures.
Assess organizational climate and identify employee and patient needs to inform customer relations and staff satisfaction programs.
Identify performance measures and actions needed to improve or correct performance, applying scientific methods to problem-solving.
Investigate and coordinate resolution and follow-up of concerns involving quality and appropriateness of patient care.
Conduct tracer methodology reviews and assess the type, appropriateness, and quality of care, treatment, and services provided to patients.
Present data and formal reports with recommendations to the Governing Body, TONHC Leadership, Chief Nurse Executive, Leadership Committee, and Medical Staff.
Help ensure health care programs address deficiencies and make optimal use of available resources.
Work with departments to develop and review performance improvement plans, reports, and data collection, and help staff make data-driven decisions.
Prepare periodic status reports and an annual evaluation of the effectiveness of the Hospital’s QAPI program.
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, and mechanisms for tracking trends, variances, and fall-outs in patient care and administrative processes.
Assess relationships among disciplines and services to support compliance and competence in standards of care, treatment, and services.
Identify, plan, and execute patient-care improvements; coach and mentor staff in achieving and sustaining change.
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 through policies, procedures, and coordination with QAPI team members.
Monitor staff development and education on Risk Management processes, including CMS compliance, the Privacy Act, and EMTALA.
Ensure risk-management data and documents are governed by 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 the hospital and three health care centers substantially comply with Joint Commission accreditation standards; conduct audits and use independent judgment to cease services when they present a risk to patient care.
Work with clinical and other leadership staff to support patient and employee-related objectives.
Supervise employees; allocate staff and other resources; establish or approve work schedules and assignments; and conduct staff meetings and conferences.
Provide written instructions and procedures for complex or non-routine assignments, and review proposed changes in functions and procedures.
Make decisions on matters not covered by precedents, protocols, or established policies.
Review records, reports, and other data to track departmental progress toward QAPI objectives and goals.
Recommend disciplinary actions and approve, modify, or reject career development plans, training requests, employee utilization proposals, and leave requests for supervised employees.
Support employee development and use available resources to carry out equal employment opportunity compliance.
Perform Administrative Call when assigned.
Develop and execute departmental budgets.
Perform other job-related duties as assigned.