QUALITY IMPROVEMENT DIRECTOR

GORDON MEMORIAL HOSPITAL•Gordon, NE

5d•Onsite

About The Position

The Quality Improvement Director leads, implements, and monitors the hospital’s Quality Assurance and Performance Improvement (QAPI) and Patient Safety programs. The role ensures regulatory compliance and drives continuous improvement in care delivery, with a focus on patient-centered care, performance improvement, and a culture of safety. The Director works closely with the Leadership Team, Board of Directors, and CEO and guides the organization on quality improvement, regulatory compliance, and patient safety best practices. The position leads the QAPI committee and oversees quality data collection, reporting, dashboards, improvement projects, compliance, risk management, medical case review, policy management, and survey readiness. It also supervises the Emergency Preparedness/Safety Coordinator and Infection Preventionist RN and serves as the hospital’s designated compliance officer and lead contact for the Community Health Improvement Plan process.

Requirements

Graduate of an accredited nursing program.
At least three years of experience in an acute care hospital setting.
BLS certification.
Knowledge of survey standards and survey processes.
Knowledge of Microsoft Office applications, including Excel, Word, and PowerPoint.
Knowledge of quality improvement processes, data collection, and statistics.
Knowledge of patient safety principles, CMS and State regulatory requirements, and electronic health records.
Analytical, technological, and interpersonal communication skills, both verbal and written.
Project management and leadership skills.
Ability to plan and organize multiple tasks.
Ability to develop education and communicate information to audiences with different needs and education levels.
Ability to handle stress under pressure and work collaboratively with staff at all organizational levels.
Ability to write policies and procedures and maintain documentation that meets or exceeds regulatory requirements.
Ability to maintain confidentiality of privileged or sensitive Patient Safety Work Product information.
Ability to apply critical thinking and problem-solving skills to quality assessment.
Ability to develop quality improvement programs, processes, and procedures.
Ability to research and locate current regulations and requirements.
Ability to develop policies and procedures using evidence-based practice and educate staff on quality improvement, patient safety, and risk reduction strategies.

Nice To Haves

Bachelor of Science in Nursing.
Master’s degree in Nursing, Hospital Administration, or Business Administration.
One year of management experience.
Current Nebraska Registered Nurse License (strongly preferred).
Certified Professional in Healthcare Quality (CPHQ).
Obtain CPHQ certification within two years of hire.

Responsibilities

Lead and chair the Hospital QAPI committee; track and monitor quality improvement projects and reports across hospital departments and contracted patient care services; prepare agendas and minutes; and provide routine reports to the Board of Directors.
Lead the annual review of the QAPI program.
Report hospital quality data accurately and on time to the contracted QIO/QIN, Medicaid Directed Payment Program, and CMS (MBQIP), as required by regulations and contracts.
Ensure collection and entry of required MBQIP, CMS, CDC NHSN, and Flex Grant quality metrics, including measures such as SDOH screening, EDTC, fall prevention, and adverse patient events.
Assist with interoperability reporting and monitoring of hospital electronic quality measures.
Maintain quality improvement dashboard metrics and work with the Leadership Team and departments to select measures and establish targets or benchmarks.
Educate staff on quality improvement tools and help design process improvement projects using general QI principles; track data and compile reports as needed.
Participate in and comply with Rural Nebraska Health Network and NHA Quality Team requirements.
Manage the Hospital Compliance Program and serve as the designated compliance officer; complete required documentation and reporting and help managers identify issues that could adversely affect the hospital’s reputation.
Stay current on laws, regulations, and licensing and regulatory agency requirements; ensure compliance with CMS and State of Nebraska hospital regulations and facilitate survey readiness.
Serve as risk management coordinator; evaluate adverse events, patient safety issues, and complaints; maintain confidential records and reports; and submit occurrences to the malpractice liability insurance carrier or Patient Safety Organization as applicable.
Coordinate medical case review and peer review requirements; coordinate and take minutes for the Morbidity and Mortality Committee; maintain case review records; and assist with case submissions under the medical director’s direction.
Facilitate policy review and management, including required annual or biennial review of facility policies and procedures by department leadership.
Supervise the Emergency Preparedness/Safety Coordinator and Infection Preventionist RN.
Serve as the lead hospital contact for the Hospital Community Health Improvement Plan process; assist with data collection and attend MAPP or Planning Committee meetings as requested by Panhandle Public Health District.
Perform other duties as assigned.