Director of Quality

DESTINY SPRINGS HEALTHCARE LLC•Surprise, AZ

10h•$100,000•Onsite

About The Position

The Director of Performance Improvement is responsible for directing and monitoring the facility-wide quality management assessment and quality performance improvement program, ensuring the facility’s programs compliant with all regulatory agencies, TJC, CMS and state and federal agencies. The Director of Quality may also be assigned to participate in the Administrator On Call (AOC) rotation to provide after-hours support for urgent operational, clinical, or safety matters, ensuring compliance with Arizona state regulations.

Requirements

Valid Level One Fingerprint Clearance.
Bachelor’s Degree from an accredited college or university in Nursing, Social work or related behavioral health field preferred, or equivalent combination of education and experience.
Four (4) years of experience in quality management/improving organizational performance within an acute psychiatric treatment setting.
A strong knowledge of TJC, OBHL, ADHS, CMS, OSHA and Patient Rights standards, and any other applicable federal and state laws and regulations governing mental health care facilities.
Knowledge of quality management principles, practices and techniques.
Knowledge of performance improvement planning techniques and goals.
Knowledge of computers and various software.
Strong analytical interpretation skills.
Skill in organizing and prioritizing workloads to meet deadlines.
Skill in telephone etiquette and paging procedures.
Effective oral and written communication skills.
Ability to communicate effectively with patients and co-workers.
Ability to adhere to safety policies and procedures.
Ability to use good judgement and to maintain confidentiality of information.
Ability to work as a team player.
Ability to demonstrate tact, resourcefulness, patience and dedication.
Ability to accept direction and adhere to policies and procedures.
Ability to recognize the importance of adapting to the various patient age groups (adolescent, adult and geriatric).
Ability to work in a fast-paced environment.
Ability to meet corporate deadlines.
Ability to react calmly and effectively in emergency situations.
Ability to supervise personnel.

Nice To Haves

Master’s degree preferred.

Responsibilities

Provide a broad vision in the continuous development and direction of quality management and quality improvement programs for the facility.
Provide direction and consultation to all staff members on the concepts of Quality Assessment and Improvement Plan and the use of total quality management tools in the application of patient care.
Consult with senior staff and directors in the development of department specific programs and quality measures which are within the standards of TJC, CMS, OBHL, OSHA regulations and all other applicable federal, state or local law/regulations governing health-care entities.
Develop a facility-wide performance improvement plan which meets or exceeds all regulatory standards and develop performance measurement indicators.
Provide continuous support in the analysis of performance improvement goals and objectives, re-establishing requirements which will facilitate continuous improvement.
Review the results of performance improvement requirements with each department director, define performance improvement requirements for the department and involve other departments/services in the problem-solving process when situations span over more than one department.
Establish a system for collecting and analyzing statistical data relating to performance improvement measures.
Ensure any detected deficiency in meeting quality improvement goals and objectives is addressed with appropriate management in a timely manner.
Provide consultation to the medical staff in carrying out all the medical staff reporting functions (i.e. drug usage, evaluation, pharmacy, and therapeutics, infection control, utilization review, quality improvement, safety and risk management and medical records review).
Prepare annual Quality Assessment and Improvement Plan, Patient Safety and Risk Management appraisals.
Conduct quality improvement meetings on a regular basis to develop and continuously encourage a facility-wide team effort in meeting quality improvement efforts.
Manage performance improvement data and information flow, as outlined in the Quality Assessment and Improvement Plan
Maintain a performance improvement record for all contract service providers.
Develop and maintain a record on performance improvement activities and all committee minutes associated with quality programs.
Design, implement and direct the Quality Management Program.
Analyze statistical data of the program to determine and respond to trends.
Design, implement and direct the Patient Advocate program.
Support the Chief Executive Officer in preparing and presenting the results of facility performance improvement activities, as well as the functioning of all Medical Staff committees to the Governing Board on a quarterly basis.
May be assigned to participate in the Administrator On Call (AOC) rotation to provide after-hours support for urgent operational, clinical, or safety matters, ensuring compliance with Arizona state regulations.
Provide services to current referral sources to assure their satisfaction and continued associations.
Ensures the implementation of an ongoing system of program orientation for patients, families, professionals and others.
Provide educational and professional development.
Adhere to facility, department, corporate, personnel and standard policies and procedures.
Attend all mandatory facility in-services and staff development activities as scheduled.
Adhere to facility standards concerning conduct, dress, attendance and punctuality.
Support facility-wide quality/performance improvement goals and objectives.
Maintain confidentiality of facility employees and patient information.