Summary:

Responsible for planning and implementing the performance improvement program to meet the needs of the hospital. Provides education to medical staff, hospital staff, and Governing Body. Facilitates performance improvement activities, and CQI activities throughout the hospital. Acts as resource person to administrative team, department managers, and medical staff. Performs clinical risk management functions. Assists department managers with preparation for medical staff committees. Oversight responsibility for all regulatory body surveys, such as, JCAHO, State Licensing Review, HCFA (CMS) Validation surveys. Maintains oversight responsibility for all performance improvement activities conducted throughout the hospital.

Essential Functions:

Responsible for planning and implementing the performance improvement program to meet the needs of the hospital.

• Facilitates performance improvement and CQI activities throughout the hospital through effective organizational skills and ongoing interaction with clinical chairpersons, nurse managers, ancillary department managers, administrative team, and Governing Body to facilitate the hospital-wide Performance Improvement program
• Maintains awareness of changes in the regulations and requirements by accrediting bodies and current methodology and practices
• Manages and operates equipment safely and correctly
• Communicates appropriately and clearly to physicians, staff, CNO and administrative team
• Uses database systems to document occurrences, medical staff review functions, committee review and actions.  Compiles reports for committees and administrative team
• Oversees preparation for review by regulatory agencies, educates and assists department managers to maintain appropriate policies and procedures to fulfill requirements and regulations
• Maintains a good working relationship both within the department and with other departments.  Consults with other departments as appropriate to collaborate in patient care and performance improvement activities
• Participates in risk management and safety activities
• Provides support and assistance to medical staff officers, committee chairpersons and Governing Body, as required
• Utilizes information obtained via performance improvement activities to seek and act on opportunities to improve patient care processes
• Maintains employee safety as a focus of practice
• Uses appropriate reporting mechanisms as required by state laws
• Compiles patient data and prepares outcome analysis
• Provides educational resources to the employees as appropriate
• Serves as a clinical resource person to staff and physicians

Knowledge/Skills/Abilities:

• Excellent oral and written communication and interpersonal skills
• Basic computer skills with working knowledge of Microsoft Office, word-processing and spreadsheet software
• Knowledge of current state, federal and local laws and regulations governing employee healthcare needs
• Knowledge of accreditation standards and compliance requirements
• Ability to demonstrate critical thinking, appropriate prioritization and time management skills
• Ability to work under stress and to respond quickly in emergency situations
• Ability to spend a limited amount of time on travel required
• Approximate percent of time required to travel: 

Salary Range: $95,000 - $145,000/year

Education:

• Bachelor’s degree

Licenses/Certification:

• Certified Professional Healthcare Quality (CPHQ) certification preferred

Experience:

• Minimum three years’ experience in Quality and/or Risk Management in a hospital setting