Dir of Qual Mgmt - Acute Care

Job Summary

The Director of Quality Management - Acute Care directs department activities, which includes quality data management and analysis, initiation of evidence based practices, identification of required education of clinical staff and leadership and oversight of compliance with regulatory standards (DNV, CMS, DHEC, Leapfrog). Responsible for planning, developing, maintaining and evaluating the hospital-wide quality management and infection prevention and control programs. Responsible for oversight of the acute hospital Clinical Documentation Improvement (CDI) program.  Collaborates with system-wide hospital leadership to ensure the quality improvement goals and metrics are aligned with the goals of the organization. Offers strategic direction and leadership to achieve quality excellence.

Minimum Qualifications

Minimum Education: Master's Degree in Nursing, Healthcare Admin, or Related Field
Minimum Years of Experience: 5 Years of quality and patient safety/performance improvement leadership or hospital management, in an acute care facility.
Substitutable Education & Experience: None.
Required Certifications/Licensure: Currently Licensed as a Registered Nurse (RN) by the State Board of Nursing for South Carolina;

Current CPHQ certification or received within 12 months of employment.
Required Training: Knowledgeable of regulatory and accrediting agencies' requirements, experience with Midas preferrred

Essential Functions

• Provides direction and supervision of quality and infection control team members, activities, systems, and services.
• Directly accountable for organizing and leading external regulatory surveys such as DNV, DHEC, CMS, and Leapfrog Safety reporting.
• Tracks performance relative to national benchmarks providing feedback/date to leadership and guidance toward effective performance improvement interventions.
• Contributes to teamwork and creates harmonious, effective and positive working relationships with others. Maintains confidentiality.
• Leads/supports multidisciplinary teams to prepare measures and related results to assign priority recommendations to executive leadership.
• Ensures a standardized communication process for strategy and engagement, as well as communication/collaboration across the continuum for each service line to identify process gaps which may affect quality outcomes. Shares evidence based practices across with multidisciplinary teams and medical staff committees.
• Outstanding leadership, communication, collaboration, and change management skills required as this role oversees organizational performance improvement as well as performance improvement and peer review for all medical staff departments and committees.
• Shares knowledge with others and promotes growth and development of others.
• Develops and revises policies and procedures necessary to support quality improvement.
• Develops department(s) goals which are aligned with the LMC System Strategic Plan and Priorities.
• Works closely with Risk Management Department, Nursing Leadership and Medical Staff to identify opportunities for improvements related to patient safety.
• Provides direct leadership for quality management and infection control team members and informal/indirect leadership to LMC leaders/team members engaged in quality initiatives.
• Identifies educational needs which are data driven and outcomes based for clinical staff and collaborates with educators/mentors to create/implement solutions.
• Embodies the behaviors, philosophy, and values which serve to uphold the ideals and enhance the image of Lexington Medical Center.
• Participates in hospital medical staff committee meetings and promotes performance improvement initiatives.
• Teaches appropriate stakeholders how to collect and maintain appropriate metrics, values, and registry data to assure/validate process improvements and outcomes.
• Attends and serves on professional civic service organizations as hospital representative.
• Responsible for own professional growth and development.
• Functions as a professional role model for other staff.
• Promotes research and data analysis.
• Assesses human resource needs; plans and evaluates employee activities to ensure safe, effective and fiscally sound operations.
• Develops standards of performance for staff within the department, conducts performance appraisals and oversees disciplinary actions within the department.
• Responsible for development and adherence of FTE budget.

Duties & Responsibilities

• Knowledgeable of HR processes and uses HR personnel appropriately.
• Promotes continual learning environment which provides opportunities for the continued professional development and broadened clinical knowledge of staff
• Works closely with the medical staff, hospital departments and administration to coordinate regulatory compliance and coordinates surveys.
• Implements measures to assure productivity and efficient use of resources within department
• Provides guidance for material resources with appropriate consideration for patient/staff needs, hospital policies and procedures and budgetary constraints.
• Responsible for the development and adherence to operating and capital budget based on projected needs and constraints.
• Evaluates and monitors the utilization of appropriate resources based on analysis of needs.
• Keeps abreast of current trends and innovations in resources through benchmarking and other cooperative activities.
• Implements systems to streamline and provide efficiency related to data management and analysis.
• Identifies opportunities to improve patient care, health care practice and interaction with health care partners; and initiates and/or participates in development of action plans to achieve desired outcomes.
• Coordinates organization-wide PI Plan and updates leadership on achievements routinely.
• Works closely with other healthcare leaders to establish quality indicators and to implement measures to achieve goals.
• Evaluates programs and effects changes as needed to ensure compliance with regulatory requirements.
• Utilizes resources within the department to provide structure for flow of information and desired initiatives between hospital leaders, clinical nurse experts and quality management team members.
• Communicates effectively throughout the health care system.
• Excellent presentation skills and able to modify presentations appropriately based upon audience.
• Directs the preparation and maintenance of departmental reports.
• Prepares quality reports for leadership, medical staff, board and various committees.
• Directs the flow of quality information to the appropriate department or committee or to administration according to the hospital Performance Improvement Plan.
• Keeps VP, other Executive Leadership and team members informed of Regulatory updates/standards changes (CMS, DNV, SCDHEC, Leapfrog).
• Maintains efficient flow of communication throughout services by keeping staff informed of organizational issues.
• Performs all other related duties as assigned or requested.