Director of Quality Improvement -- Corporate Nursing -- Stonewall Jackson Memorial Hospital - 76618

Director of Quality Improvement

The Director of Quality Improvement will be a member of the senior leadership team at Stonewall Jackson Memorial Hospital with reporting relationships both to the Chief Executive Officer and Mon Health System Quality Leadership. The Director of Quality Improvement is responsible for providing overall vision and direction for all aspects of quality, patient safety and process improvement for Stonewall Jackson Memorial Hospital, and also serve as a vital member of the Mon Health System Quality team to ensure alignment with Mon Health System Quality programs and initiatives.

The Director of Quality Improvement ensures that the organization provides the highest quality care in a safe, timely and patient centered manner. Provides executive leadership and direction ensuring the organization meets accreditation and regulatory standards and fulfills reporting requirements. Develops and expands continuous clinical performance improvement through the setting of priorities, allocation of resources, oversight of policies and procedures and the setting and execution of strategic plans.

This position will also provide facility support for the Mon Health System led compliance and risk management programs; to include compliance, risk and legal issue reporting, coordinating systems for compliance and risk identification, investigation and analysis; and coordination of education.

People and Culture

· Effectively manage activities of department staff

· Maintains staff performance results by coaching, counseling and disciplining employees; planning, monitoring and appraising job results

· Maintains and supports staff in professional and technical knowledge by educational conference attendance; professional network establishment; and professional organization participation

· Develop and foster effective collaboration between clinical departments to ensure an integrated approach to quality, safety and performance improvement.

· Communicate effectively to facilitate positive working relationships and achieve desired outcomes

· Provide hospital quality and performance improvement education to the workforce including the medical staff

Integration and Efficiency

· Oversee the processes that provide relevant reports, data and education to support quality improvement and fulfill reporting needs. Reporting needs include national benchmark surveys, national rankings, accreditation requirements, third party payor requirements, regulatory agency requirements, peer review.

· Monitor and evaluate and improve activities related to the quality of patient care. This includes benchmarking activities with CMS and any other vendors or agencies utilized.

· Meet regularly with Senior Leaders, Medical Staff members, and other Department Management to provide detailed reports on all serious incidents, claims, risk-related issues; submit monthly incident reports, as applicable, to the Credentials and Review Committee.

· Prepare reports to appropriate Committees on processes for improvement, trends and actions identified by the Quality Department.

· Assists the Corporate Compliance Officer with maintaining an effective compliance communication program for the organization, including promoting (a) use of the Compliance Hotline; (b) heightened awareness of Standards of Conduct, and (c) understanding of new and existing compliance issues and related policies and procedures.

· In coordination with the MHS Compliance Officer, monitors and reports the performance of the Hospital Compliance Program and related activities on a continuing basis, taking appropriate steps to improve its effectiveness.

· Collaborates with other departments (e.g., Risk Management, Internal Audit, Human Resources, etc.) to direct compliance issues to appropriate existing channels for investigation and resolution. Consults with the Corporate attorney as needed to resolve difficult legal risk/compliance issues.

· Identifies potential areas of compliance vulnerability and risk; develops/implements corrective action plans for resolution of problematic issues and provides general guidance on how to avoid or deal with similar situations in the future.

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