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    Director of Quality/Education/Regulatory Compliance - Campbellsville, United States - Taylor Regional Hospital

    Taylor Regional Hospital
    Taylor Regional Hospital Campbellsville, United States

    2 weeks ago

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    Description


    The Director of Quality/Education/Regulatory Compliance will be responsible for continuing education, staff development, orientation, patient education, student rotations, library and resource management and community education.

    The Director will also be responsible for strategic planning for quality improvement activities associated with data abstraction.

    Responsibilities
    Directing and coordinating all department activities of Quality as related to data collection/abstraction, submission and distribution and reporting.


    Effectively synthesizes, analyzes and communicates all quality measures to clinical and medical staff as they relate to inpatient/outpatient and office patient procedures.

    Manages and directs implementation of The Joint Commission's Hospital Accreditation Standards Manual.

    Chairs the monthly continuous survey readiness committee.

    Ensures accuracy and timeliness to responses from The Joint Commission's survey.

    Provides direction to the Department Directors/Office Coordinators on The Joint Commission standards and the findings from the Continuous Survey Readiness Committee.

    Facilitates and coaches leadership, team members and physicians in best practices and process improvement.
    Cultivates and manages hospital relationships with accreditation organizations.

    Arranges for mock surveys.

    Facilitates corrective action and response to mock survey findings.
    Coordinates and directs rounding by Tracer Teams and reports findings through Quality Committee.


    Provides evidence of an ongoing program which conforms to The Joint Commission standards and state regulation in all Joint Commission survey that involve Taylor Regional Hospital.

    Plans and promotes implementation of quality improvement/CQI program hospital-wide and continually evaluates hospital's quality improvement/CQI program and effects changes as needed to improve programs and ensure the hospital's compliance with regulatory requirements.

    Makes recommendations to Department Directors.

    Services as a resource person to the hospital's committee function as requested in regard to policies and procedures, medical staff bylaws, rules and regulations and external regulatory function.

    Also coordinates with medical staff coordinator/CEO for appropriate quality measures are addressed and applied to ensure owned physician contracts.
    Plans, organizes and evaluates hospital patient and community education services.

    Directs, develops and maintains current curriculum for an educational course of study that coordinates academic and technical materials.
    identifies opportunities to improve patient safety.

    Identifies patient safety risks, conducts Failure Mode Effective Analysis (FMEA) for new processes being implemented, as appropriate.

    Leads the organization in the identification of new safety initiatives as identified by accrediting and and regulatory bodies.

    Coordinates and manages Leapfrog, HRIP and other Quality Programs to ensure that quality measures are met by coordinating with Department Directors to ensure that they have most up to date requirements and information to meet requirements.

    Responsible for accuracy and submission of associated data.
    Develops recommendations for departmental budget for operations and ensures departments operate within that budget.
    Assumes responsibility for computer data entry, integrity of information and prompt completion of requested projects.

    Assures timely, accurate and consistent completion of all team member related functions including hiring, training & orientation, competency, discipline, in-services.

    Conducts monthly department meetings and maintain minutes.

    Communicates and assists with clinical documentation opportunities to medical, nursing, clinical and support staff.
    Serves as Chairperson of Quality Council.

    Provides quarterly reports and dashboards relating to Quality through the appropriate committee structure including Board of Trustees.

    Qualifications
    Bachelor's Degree in Nursing Required.

    Valid Kentucky RN License.

    BLS Instructor course within 1 year of employment. 5-9 years of nursing experience required, 5-9 years of management experience required.

    Full Time Day Shift position available.

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