Cullman Regional Medical Center Inc
QUALITY DIRECTOR
Cullman Regional Medical Center Inc, Cullman, Alabama, us, 35056
Job Summary:
The Quality Director provides leadership resulting in high quality, safe care by assuring Cullman Regionals systems and processes comply with the Joint Commission accreditation standards, federal, state, and other regulations. This leader facilitates and supports licensing, accrediting, and regulatory compliance activities. Partners with senior leadership, department and clinical leaders, and medical staff to assess and improve quality outcomes. Provides oversight, education, and guidance to meet regulatory standards, survey readiness, and improve the quality of patient care. Manges the policy and procedure review process assuring that procedures are current and reflect evidence-based best practices. This Director is a key leader in organizing clinical and medical staff teams to accomplish organizational and quality goals.
Key Responsibilities :
Functions as the primary contact for all regulatory agencies: Supervises contact when regulatory agencies are on-site
Development of and compliance with CMS QAPI standards, works to implement the Performance Improvement and Patient Safety Plan.
Prepares leaders and team members by educating and updating on regulatory standards
Evaluate issues by assessing continuity and consistency in compliance with regulatory requirements
Improves operational efficiency of regulatory and quality metric reporting and addresses identified opportunities to improve clinical quality across the enterprise.
Collaborates with clinical and medical staff leaders to develop and implement corrective action maximizing effectiveness and educational opportunity
Leads the preparation for surveys and inspections for all regulatory agencies.
Cultivates and maintains relationships with representatives of regulatory agencies.
Creates a culture of continuing compliance and patient safety.
Manages staff to improve operational efficiency in public reporting, improving clinical core measure outcomes, and improve results in Patient Blood Management, Bariatric program results and NSQIP outcomes.
Provides oversight and guidance to staff addressing regulatory and public reporting requirements.
Works collaboratively to maintain certifications and improve care under Joint Commission Disease-specific certification
Provides education and direction to leaders by addressing quality improvement across all service lines
Qualifications:
RN license with degree in Nursing or Clinical field with Masters degree in Nursing or healthcare-related field, preferred
Minimum of 5 years clinical experience with 5 years of clinical operations management experience leading change, designing and improving workflow/work processes preferred
3 years recent experience in Joint Commission Survey preparation and Continuous Survey Readiness activities for hospitals and clinics .
Extensive knowledge of accreditation standards applicable to Hospitals and Clinics
Recent experience with CMS, State and Joint Commission surveys
Certified Professional in Healthcare Quality (CPHQ), preferred
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The Quality Director provides leadership resulting in high quality, safe care by assuring Cullman Regionals systems and processes comply with the Joint Commission accreditation standards, federal, state, and other regulations. This leader facilitates and supports licensing, accrediting, and regulatory compliance activities. Partners with senior leadership, department and clinical leaders, and medical staff to assess and improve quality outcomes. Provides oversight, education, and guidance to meet regulatory standards, survey readiness, and improve the quality of patient care. Manges the policy and procedure review process assuring that procedures are current and reflect evidence-based best practices. This Director is a key leader in organizing clinical and medical staff teams to accomplish organizational and quality goals.
Key Responsibilities :
Functions as the primary contact for all regulatory agencies: Supervises contact when regulatory agencies are on-site
Development of and compliance with CMS QAPI standards, works to implement the Performance Improvement and Patient Safety Plan.
Prepares leaders and team members by educating and updating on regulatory standards
Evaluate issues by assessing continuity and consistency in compliance with regulatory requirements
Improves operational efficiency of regulatory and quality metric reporting and addresses identified opportunities to improve clinical quality across the enterprise.
Collaborates with clinical and medical staff leaders to develop and implement corrective action maximizing effectiveness and educational opportunity
Leads the preparation for surveys and inspections for all regulatory agencies.
Cultivates and maintains relationships with representatives of regulatory agencies.
Creates a culture of continuing compliance and patient safety.
Manages staff to improve operational efficiency in public reporting, improving clinical core measure outcomes, and improve results in Patient Blood Management, Bariatric program results and NSQIP outcomes.
Provides oversight and guidance to staff addressing regulatory and public reporting requirements.
Works collaboratively to maintain certifications and improve care under Joint Commission Disease-specific certification
Provides education and direction to leaders by addressing quality improvement across all service lines
Qualifications:
RN license with degree in Nursing or Clinical field with Masters degree in Nursing or healthcare-related field, preferred
Minimum of 5 years clinical experience with 5 years of clinical operations management experience leading change, designing and improving workflow/work processes preferred
3 years recent experience in Joint Commission Survey preparation and Continuous Survey Readiness activities for hospitals and clinics .
Extensive knowledge of accreditation standards applicable to Hospitals and Clinics
Recent experience with CMS, State and Joint Commission surveys
Certified Professional in Healthcare Quality (CPHQ), preferred
#J-18808-Ljbffr