Position Purpose: The Director, Quality Resources provides leadership for and management of Quality/Performance Improvement, Patient Safety, Infection Prevention and Control, Patient Experience, and clinical initiatives for Sepsis and Stroke. The Director, Quality and Patient Safety facilitates regulatory compliance activities throughout the organization and acts as a liaison between federal, state, and other accrediting bodies.
Essential Functions
1. Leads development and implementation of hospital wide Performance Improvement activities. Annually reviews and revises, where necessary, the facility Performance Improvement Plan. Assists Directors and Managers in all Ancillary, Nursing and Medical Staff departments in identifying and implementing Performance Improvement Objectives.
2. Provides leadership and supervision for the management of Quality Assurance/Performance Improvement, Infection Control, Patient Satisfaction and External Regulatory Agency compliance activities. Assures effective manpower utilization, development and performance. Develops budget for area and ensures operations are within budget. Participates in decisions to employ, develop, evaluate, transfer and when necessary terminate subordinates.
3. Oversees data collection required for Joint Commission and all publically reported requirements including Core Measures. Assures timely submission of data through selected vendor. Coordinates System preparation for Joint Commission survey.
4. Facilitates the Systems compliance with External Agency requirements by coordinating site visits, routing updated requirements to appropriate individuals, coordinating responses to identified deficiencies, and communicating open issues to appropriate Administrative staff. Assures education of all entities and staff within the hospital on the principles, tools and concepts to support Performance Improvement and External Regulatory Agency compliance.
5. Monitors, trends and analyzes all Performance Improvement data, including Medical Staff Peer review. Assures reporting of all significant trends/issues to the appropriate committees and senior leadership. Assist in developing corrective action plans and appropriate follow up.
6. Serves as Patient Safety Officer. Actively participates in Risk Management and Patient Safety activities related to all events that are designated as “near miss” or “sentinel”. Provides leadership for the development of the Root Cause Analysis and Corrective Action Plan for all such events.
Marginal Functions
Ø Performs both essential and marginal job functions in a safe manner as identified by Saint Anthony Hospital and the respective department while adhering to the Hospital’s confidentiality norms and standards. Actively and consistently demonstrates the core values of Saint Anthony Hospital in all interactions with others.
Ø Assumes responsibility for knowing and maintaining established hospital and departmental objectives, policies/procedures including general sanitation, safety, environmental and infection control standards.
Ø Participates in performance activities including problem identification, data collection, solution selection, implementation and evaluation. Also assists in the care and maintenance of departmental equipment and supplies as appropriate.
Ø Participates in staff meetings and other inservices, meetings or committees as required.
Ø Maintains knowledge of changes in the health care industry related to regulatory standards. Continually evaluates and updates initiatives, recommending changes and revisions to assure compliance with the most current requirements.
General Job Requirements
· Previous success with Joint Commission survey in a Hospital setting
· Ability to interpret, design and implement programs utilizing word processing and spreadsheet programs
· Proven experience in establishing and evaluating process improvement systems
· IL RN License
Reporting Relationship
Positions reporting to this position include: Infection Control Practitioner, Patient Experience Manager, Accreditation Manager, Core Measure & Public Reporting Manager, Healthcare Data Analyst, Performance Improvement Specialist
Machines, tools, equipment and work aids required: General office equipment; Other Equipment Includes
Featured benefits
- Comprehensive Health Insurance Plans/Dental/Vision
- Flexible Spending Account/Health Savings Account
- Employer-matching Retirement Plans
- Paid Time Off & Holidays
- Bereavement Leave/Short Term Disability/Basic & Supplemental Long-Term Disability
- Basic & Supplemental Life Insurance/Accidental Death & Dismemberment Insurance
- Business Traveler’s Accident Insurance
- Critical Illness/Accident Insurance
- Pet Insurance/Legal Insurance
- Tuition reimbursement/Adoption Assistance
- Qualifying Employment for the Public Service Loan Forgiveness Program
Salary Range
$61.10 - $94.36
PI270403573
