Director of Quality RN

Director of Quality

The Director of Quality assists in the overall coordination of the hospital-wide Performance Improvement Program. Assists the hospital and medical-staff leadership in meeting The Joint Commission and CMS Standards as well as other state and federal regulatory requirements, complying with corporate policies and procedures. Promoting teamwork with physicians and all health-care providers in achieving Quality benchmarks. Responsible to provide comprehensive assessment, planning, monitoring, and evaluation for compliance with accreditation and regulatory agencies including any state licensing standards. The Director shall investigate regulations, standards, and laws and make initial recommendations to ensure compliance with all regulatory and accrediting entities. The Director will translate standards, requirements, and policies into terms or processes meaningful to the staff and provide consultation and education to relevant taskforces, quality action teams, and committees to ensure ongoing compliance with standards. The Director will ensure an ongoing mechanism for proactive monitoring and auditing is developed, continually updated, and executed on a regular schedule and the results of any monitoring or auditing are made available to the appropriate leadership. The Director is responsible for directing and coordinating regulatory and accreditation functions, ensuring appropriate preparation, and active participation of appropriate staff and managers for agencies such as The Joint Commission (TJC), Floridas Agency for Healthcare Administration (AHCA), and / or the Centers for Medicare and Medicaid Services (CMS) and to formulate responses to accreditation findings and inquiries.

Directs development of specific short and long-range programs and project plans to obtain the facility objectives. Facilitates, develops, and implement special projects as assigned by the VPQ and CMO. Develop audit systems, perform data analysis and prepare reports related to measuring objectives and tracking outcomes. Oversees regulatory readiness, quality measurement, public reporting, and pay-for-performance programs and initiatives, holding staff and departments accountable for achieving performance goals. Facilitate Continuous Quality Improvement teams as requested. Facilitate planning sessions as requested. Supporting evidence based practices, the reduction of medical / health care errors. Serves as an integral part of the multidisciplinary team overseeing the departments activities across the health care setting directing and managing the daily operations of the department. Tracks and updates Work Plan activity progress, identifies barriers and actively problem solves to mitigate risk. Assures application of a tracking method to monitor progress towards goals by collecting accurate, timely data to display the quality, cost, and service outcomes. Develop audit systems, perform data analysis and prepare reports related to measuring objectives and tracking outcomes. Assists with coordination of monthly QI Meetings. Provides direction to the staff and supervisors of the Quality Management Department. Reviews performance of the department staff and approves staff evaluations. Responsible for appropriate disciplinary action of staff members as needed. Responsible for ensuring the facility and department meets and adheres to all applicable federal, state, The Joint Commission, and local regulatory agency requirements and for ensuring the department and facilities success in any regulatory survey. Collaborates with other department directors when necessary to resolve procedural difficulties, clarifying department responsibilities, objectives and resolving identified problems. Responsible for special projects as assigned by the Administrative Management Team. Meets all objectives as set forth in individual evaluation and displays a good work attitude towards job responsibilities. Other duties as assigned.

Demonstrated success and abilities in leadership, achieving results, communications, customer service and health care management. 3 - 5 years Quality Leadership experience required 5 -7 years Hospital-based experience required Bachelor's Degree in Nursing; Post Graduate Degree in Nursing or Healthcare related field required or in process RN license in the State of Florida CPHQ (Certified Professional in Healthcare Quality) OR CHCQM (Diplomate in American Board of Quality Assurance and Utilization Review Physicians)