Director Quality, Clinical Safety and Infection - Lancaster, United States - Antelope Valley Medical Center

Antelope Valley Medical Center

Verified Company

Lancaster, United States

3 weeks ago

Posted by:

Mark Lane

beBee recruiter

Description

Job Objective:

Responsible for directing performance improvement, and clinical safety. Provide leadership and support for the development, implementation, and evaluation of quality

improvement initiatives in conjunction with the Administrative team. Direct and manage accreditation, regulation and licensing activities.

Essential Duties and Responsibilities:

***Position Specific —

Provides consultation and guidance to the organization and medical staff in the design, monitoring and evaluation of performance improvement activities.
Directs peer review activities in collaboration with physician advisor
Works closely with Medical Director of Quality
Recommends appropriate Process Improvement team formation to the Quality Management and Safety Committee
Acts as facilitator for Process Improvement Teams
Directs the clinical safety program including risk identification, case review, and hospitalwide quality review reporting system\
Collaborates with Claims Management on Quality or Clinical Safety issues.
Provides input at the highest level of Nursing Administration regarding the impact of decisions on the quality of services provided
Serves as an appointed member of the Nursing Leadership Committee as resource and consultant
Oversees and participates in medical record review
Develops and revises organizational policies to assure compliance with current health care law and riskrelated issues for Administrative/Board approval.
Directs, coordinates and conducts interdisciplinary intense analysis activities/meetings to establish risk reduction strategies and action plans
Works collaboratively with Nursing Directors to promote standards of nursing practice
Directs the integration of infection control into performance improvement activities
Directs CQI functions of facility to meet Joint Commission, State and Federal requirements for hospital and Medical Staff
Directs survey preparation activities including coordinating mock surveys and organization assessment activities identifying areas requiring improvement
Plans, develops and conducts accreditation and regulation education and orientation activities
Coordinates accrediting and regulatory agency surveys
Coordinates development of written response reports to regulatory and accrediting bodies such as CMS, DHS and Joint Commission.
Provides education regarding current Quality Management regulations for Joint Commission, CMS, Department of Public Health, and insurance providers with employees and Medical Staff
Provides reports on quality activities to the appropriate departments, including the Board of Directors
Protects patient confidentiality
Conforms with Affirmative Action guidelines

Leadership and Management —

Develops and implements departmental goals and objectives with input from staff members
Develops and implements departmental policies and procedures that guide and support the provision of services
Interacts with all customers to ensure prompt and accurate communication as needed to provide the service expected and to meet the goals of the service
Evaluates problems, and develops and implements solutions
Develops new ideas and/or systems with innovation and creativity
Challenges the status quo in looking for more efficient practices
Leads by example and serves as a professional role model
Updates employees on present as well as future changes
Actively listens and tries to understand before responding
Shapes an environment that is psychologically safe, encouraging, and nonjudgmental
Supports, encourages, and contributes to the professional growth of all department employees
Understands, teaches and implements elements of empowerment and team building
Responsible for the maintenance of quality control programs as appropriate
Responsible for the continuous assessment and improvement of the quality of care and services provided
Adheres to all Compliance & Integrity Program rules and requirements
Attends and completes Compliance & Integrity training

Human Resources Management —

Conforms with Equal Employment Opportunity Commission guidelines
Recognizes, appreciates and capitalizes upon the differences people bring to the job
Sees diversity as an advantage
Selects staff who possess and demonstrate the required competencies and values and maintain the Customer Service Expectation and Standards of the hospital
Develops and implements job descriptions and performance standards
Evaluates staff performance per established policy, including the use of staff competence and quality improvement data
Mediates personnel problems and resolves complaints using good problem solving techniques
Demonstrates knowledge of and competently interprets and administers Hospital policies and procedures
Conforms to the hospital Wage and Salary Administration and Recording of Hours Worked policies
Ensures that staff is in compliance with licensure and other annually mandated r