Area Director of Quality

Area Director Of Quality

The Area Director Of Quality provides clinical leadership for the following areas : Medical Staff Services, Regulatory Compliance, Risk Management, and Quality Management / Improvement. This position must integrate company values into daily practice.

Essential Functions

• Facilitates compliance for the Hospital related to CMS, The Joint Commission, and State / Federal regulations. Completes audits to identify ongoing compliance.
• Makes Hospital visits at least quarterly, or as needed, to assigned hospitals to perform onsite analysis of ongoing performance of quality program.
• Prepares Medical Staff, hospital and hospital staff for survey activities by regulatory and accrediting agencies. Drafts survey responses to regulatory and accreditation agencies.
• Collaborates with the medical staff regarding functions related to medical staff privileging and credentialing, performance improvement measurements, professional practice evaluation development and reviews, and aggregation by practitioners.
• Facilitates the hospital performance improvement program through the collaboration with other hospital leaders. Provides guidance regarding measurements, data collection, analysis, conclusions, and process improvement.
• Implements and manages clinical risk management functions including incident reporting, investigational follow up, grievances, root cause analysis, provides notices of potential claims, and litigation management in conjunction with senior leadership.
• Educates Medical Staff and hospital employees during initial orientation, re-orientation, and as education in area of expertise is indicated.
• Ensures submission of data to internal and external databases, as required by accreditation and regulatory agencies, is submitted timely and accurately.
• Provides an environment conducive to safety for patients, visitors, and staff.
• Assesses the risks for safety and implements appropriate precautions.
• Shares patient satisfaction data with leadership / staff monthly and coordinates improvement. Identifies opportunities for improvement and coordinates the organizational efforts to improve patient satisfaction.
• Performs other duties as assigned to support overall effectiveness of the organization.

Minimum Job Requirements Minimum Education & Experience

Required Licenses, Certifications, and / or Documentation

Required Knowledge, Skills, and Abilities

Physical Requirements Over the Course of a Shift