Job description

The primary responsibility of this position is to provide leadership for the Hospital and Medical Staff Quality programs. Directs all functions, programs, and activities of the Quality programs, including quality monitoring and auditing, data reporting internally and externally, performance improvement team initiatives, and patient safety. Coordinates meetings and drafts agendas and minutes of the Medical Staff Quality Committee and Quality Performance Committee meetings. Coordinates follow-up to variances reported. Assists in leading hospital accreditation survey readiness.

Minimum Qualifications

• Texas-licensed RN with bachelor’s degree in nursing, health/public health administration, business administration, or a closely related area, master's degree preferred.
• Five years of experience in the management of quality improvement functions, or nursing/ quality management
• CPHQ or equivalent certification preferred
• Working knowledge of the principles and theories of hospital processes
• Considerable knowledge of accreditation and regulatory (CMS and other) standards.
• High degree of professionalism in interaction with peers and clients
• Ability to manage own workload and prioritize effectively
• Effective time management and flexibility skills
• Proficiency with Epic and MS Office applications including Word, Excel, Outlook, and Power Point

Essential Functions

• Develops, implements, monitors, and assures an integrated and coordinated Quality Program based on the hospital's Quality Improvement/Patient Safety Plan
• Coordinates with and provides leadership to managers and medical staff in adoption of appropriate quality indicators and performance measures, conducting appropriate monitoring and auditing, and documentation, aggregation and reporting of data, findings, analyses, conclusions, and actions/corrective actions
• Coordinates meetings and activities of the Physical Environment/Safety, Quality Performance and Medical Staff Quality Committees, including scheduling meetings, drafting agenda and minutes, and preparing documents, reports, policies, procedures, and packets for committee review
• Reviews medical records according to medical staff-selected screening criteria and prepares copies of medical record excerpts for physician and committee review.
• Provides data and reports to support the physician/LIP credentialing and peer review processes
• Coordinates and facilitates Performance Improvement teams. Oversees Performance Improvement program, providing leadership, structure, and support to PI initiatives and teams
• Leads and directs the Patient Safety function and program and integrates those functions with Quality Performance Committee functions
• Manages variance reporting process, assuring appropriate corrective action and/or follow-up to variances requiring follow-up action
• Conducts, when necessary, root cause analyses, failure mode analyses, and vulnerability analyses
• Serves on ISO audit teams
• Externally reports data and adverse events as required
• Participates in safety/environment of care rounds and certification and accreditation survey readiness activities, assuring appropriate preventive and corrective action is taken
• Implements and follows up on corrective action plans implemented for non-conformities identified
• Provides leadership in execution of Risk Management plan and strategies to identify and mitigate risk. Assists Senior Leadership as needed with legal cases
• Investigates and responds to patient grievances
• Develops and maintains professional organizational relationships
• Presents a courteous and helpful demeanor to all patients, visitors, other facility employees / medical staff members, or any other person and employee encounters while representing the facility
• Maintains current knowledge related to applicable statutes, regulations, guidelines, and standards necessary to perform job duties
• Performs other duties as assigned

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job the employee is frequently required to sit, converse, and listen; use hands to touch, handle, or feel objects, tools, or controls; and to reach with hands and arms. Specific vision abilities required by this job include close vision and the ability to adjust focus.

The employee must be able to lift and/or carry over 20 pounds on a regular basis and be able to push/pull over 25 pounds on a regular basis.

The employee must be able to stand and/or walk at least five hours per day.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Job Type: Full-time

Pay: $63,689.60 - $86,746.40 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Employee discount
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Referral program
• Retirement plan
• Tuition reimbursement
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Supplemental pay types:

• Bonus pay

Ability to commute/relocate:

• Addison, TX 75001: Reliably commute or planning to relocate before starting work (Required)

Experience:

• ISO 9001: 3 years (Required)

Work Location: In person

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