Director of Performance Improvement/Quality Assurance

The Performance Improvement Director develops, manages and integrates a comprehensive Performance Improvement (PI) Program and Infection Control (IC) Program to achieve unprecedented results in quality, efficiency, safety, satisfaction and value with transparency. 

 

The Directorial oversight responsibility of the Performance Improvement Program is to develop and share best practices for improving performance in quality, safety, perception of care, value and efficiency; to develop/ maintain scorecards for all Service Lines with defining expected outcomes & benchmarks based on Quality, Safety, Satisfaction and Value; to complete Clinical Assessment, Diagnosis and Treatment for the Service Lines. Responsible for coordinating and managing hospital wide performance improvement activities including continued survey readiness. Responsible for oversight of on-going publicly reported quality initiatives undertaken by the organization, like Core Measures, Patient Satisfaction, etc. Work collaboratively with Administration and Leadership. Ensures execution and communication of Performance Improvement and Patient Safety activities occurs from the department level to Board of Trustees. 

 

The Directorial oversight responsibility of the Infection Control Program supervises, assesses, plans, implements and evaluates the hospital surveillance, prevention/control of infection management. Assists with policy and procedure development and implementation while maintaining CDC, OSHA, TJC or AOA HFAP/DHS/CMS and other regulatory agency directives.  Acts as a primary education consultant to hospital employees, physicians, patients, volunteers and visitors in safe Infection Control/Prevention practices.  Coordinates all hospital infection control activities and interventions with the Infection Control Committee, Pharmacy & Therapeutics Committee, Medical Staff and hospital employees.  Responds to potential exposures by communicating with patients, physicians, and regulatory agencies and assisting Employee Health to communicate with employees. Collaborates with the Employee Health Nurse and assists in coordinating the hospital employee health program.  Performs safety rounds of the physical plant to ensure basic Infection Control/Prevention and safety practices are adhered to in all hospital departments to maintain a safe environment for patients, physicians, volunteers, visitors and hospital employees.

 

The scope of activities in managing the PI and IC Program, includes creating collaborative customer relationships; planning appropriate group processes; creating & sustaining a participatory environment; guiding the group to appropriate & useful outcomes; building and maintaining professional knowledge; employing evidence-based practice; integrating best research with expertise & patient values for optimal care; working in interdisciplinary teams; application of performance improvement and infection control methodologies to minimize waste, decrease errors, increase efficiency and ultimately improve care and appropriate utilization of informatics to communicate, manage knowledge with clinical expertise and patient values for optimal care.

 

Team facilitation and experience with hospital accreditation standards and survey process preferred. Knowledge of local regulatory standards & OSHA regulations a plus.

1. Bachelors Degree required, preferably in a healthcare related field.

2. Masters Degree preferred. 

3. State RN licensure or a License in healthcare field preferred.

4. 5–7 years healthcare experience. 2-6 years quality improvement experience 

5. Current BLS (AHA) certificate upon hire and maintain current.

6. Certification in Infection Control (CIC) within 36 months of hire.

7. Desired expertise in microbiology, antibiotic usage, and clinical practices.

8. Experience in reviewing charts for quality care issues.  Detail oriented organizational skills.  Must be able to handle multiple cases, directions and follow-through.

9. Good communication skills both verbally and written.  Experience with Medical Staff communication.

10. Coordination of internal departments and external entities to ensure compliance with company policies, and state/federal regulatory and accreditation standards.  

11. Certified professional in healthcare quality preferred.

 

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