Tuba City Regional Health Care-posted 2 months ago
Full-time • Senior
Tuba City, AZ
1,001-5,000 employees
Ambulatory Health Care Services

The Director of Quality and Performance Improvement will work collaboratively in the Quality Department in leading and coordinating the quality and performance improvement initiatives of the hospital, while remaining in state and federal compliance. They will work in facilitating performance improvement projects. The Director of Quality and Performance Improvement will interact with and work alongside other hospital leaders in implementing and managing hospital-wide quality initiatives. The Director of Quality & PI's responsibilities will include ensuring processes are implemented to evaluate and identify opportunities for improvement in the provision of high quality, safe and resource effective care to its patients. They will implement quality initiatives and ensure their goals are met. Ensures processes are in place to ensure compliance with Quality and Performance Improvement and as applicable working with Infection Control, Risk Management, Patient Safety, Peer Review, etc. Monitors, in partnership with the medical staff, the measured outcomes of organization-wide clinical care activities, identifies opportunities for improvement, and leads clinical improvement activities. This position is responsible for directing, plans, and organizes the staff and activities of the quality management/ performance improvement program to achieve approved clinical goals and strategic operating plans and objectives. A performance improvement program will evaluate performance in the organization and develops and implements measures to improve it. Ensures compliance with regulatory agencies in accordance with internal and external requirements/regulations. Directs departments and is fully accountable for monitoring program activities, including compliance, planning, implementing, and evaluating program development to ensure clinical and financial activities in decrease waste and adding value to the organizations overall financial stability and resources.

  • Management of the quality and performance improvement programs, ensuring quality of care and patient comes are reduced to zero.
  • Directing quality management activities which will include performance improvement, quality review, Joint Commission readiness, data collection and reporting, and core measures management.
  • Establishing policies and procedures as needed.
  • Performs other assigned duties as needed.
  • Provides leadership for system-wide development and implementation of the QI Plan in all domains of quality including patient safety and care processes in accordance with the mission and vision of CDP.
  • Develops a system for defining, identifying, monitoring, and analyzing departmental quality indicators.
  • Reviews departmental indicators on a regular basis and makes recommendations as needed to ensure quality improvement efforts are effective.
  • Identifies trends, prioritizes, and directs others in implementing recommended improvements.
  • Ensures compliance with state and federal regulations pertaining to patient safety and quality improvement.
  • Manages the data systems for patient satisfaction, producing and interpreting reports toward improvement of patient access and satisfaction.
  • Reports quarterly and annual hospital quality data as required by state and federal regulations.
  • Conducts quality improvement meetings and provides direction and education to all staff.
  • Ensures the execution and communication of performance improvement activities throughout the organization by directing others in the implementation and communication of their performance improvement activities and reporting results to the CEO and/or Board as appropriate.
  • Provides direction and participates in processes for establishing and implementing policies and procedures to address patient safety and quality of care.
  • Facilitates and/or advises internal QI project teams and QI measures.
  • Gathers and reports quality data to the following federal and state databases on a monthly, quarterly, and annual basis: Hospital Improvement Innovation Network (HIIN), National Health Safety Network (NHSN), Quality Net, Centers for Medicare/Medicaid Services Abstraction and Reporting Tools.
  • Supports and assists PI colleagues and on-site teams with data collection, reporting, interpretation, and analysis for their PI Projects. Functions as a facilitator, consultant, and/or project manager, as required.
  • Ensures high quality of both the process and results of the work, and that appropriate change management principles are applied in the areas impacted by change.
  • Manages relationships with PI leaders and key stakeholders to effectively transition responsibilities to operational partners and drive a culture of continuous improvement and data-driven decision making.
  • Skilled in working with operational, financial and clinical data from disparate sources, including EMR, payroll, general ledger, and hospital inpatient/outpatient data and process improvement.
  • Lead facility-wide standardization in targeted process improvement initiatives and evaluate success through pre-established criteria and measurement tools. Support division-wide standardization of process improvement initiatives through facility adoption and implementation.
  • Facilitate and/or lead clinical process improvement teams as needed to achieve quality and performance improvement goals.
  • Ensure proper PPE is always worn while on duty including but not limited to, face mask, gloves, gown, isolation gown, NIOSH-approved N95 filtering facepiece respirator or higher, if available), and eye or face shield.
  • Complete all donning and doffing tasks in a safe acceptable method and discard of used PPE accordingly.
  • Complete task training for all routine cleaning and decontamination processes for all surfaces contaminated by a communicable disease to ensure a high level of patient, visitor, employee and external customer satisfaction.
  • Performs other duties as assigned.
  • Bachelor's degree in nursing.
  • Master's degree in nursing, MBA, MSL or appropriate master's degree in healthcare.
  • Obtain a certification from an accredited Lean Program for a Lean yellow belt within six months of hire.
  • Must obtain black belt within 1 year of hire.
  • Must obtain master's black belt within 2 years of hire.
  • A valid, current, full and unrestricted Professional Nursing License to practice nursing in any state of the United States of America, The Commonwealth of Puerto Rico, or a territory of the United States.
  • Must maintain a current valid certification of Basic Life Support (BLS) from the American Heart Association.
  • Five (5) years of supervisory experience in quality and performance improvement in an acute-care health care setting or related healthcare clinical leadership.
  • Accessing community resources for patient referrals.
  • Knowledge of diagnosis related groups (DRG) and documentation requirements.
  • Positive working relationships with others.
  • Possession of high ethical standards and no history of complaints.
  • Reliable and dependable; reports to work as scheduled without excessive absences.
  • Ability to sense varying skill levels and direct instruction accordingly.
  • Detail oriented, well organized, and applies critical thinking, reasoning, deduction, and inference skills.
  • Knowledge of report writing, graphical analysis, and working with computer spreadsheets and database programs.
  • Completion of and above-satisfactory scores on all job interviews, demonstrating to the satisfaction of the interviewees and TCRHCC that the applicant can perform the essential functions of the job.
  • Successful completion of and positive results from all background and reference checks, including positive employment references from authorized representatives of past and current employers demonstrating to the satisfaction of TCRHCC a record of satisfactory performance and that the applicant can perform the essential functions of the job.
  • Successful completion of fingerprint clearance requirements, physical examinations, and other screenings indicating that the applicant is qualified to be employed by TCRHCC and demonstrating to the satisfaction of TCRHCC that the applicant can perform the essential functions of the job.
  • Submission of all required employment-related documents, applications, resumes, references, and other required information free of false, misleading or incomplete information, as determined by TCRHCC.
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