Director of Quality Management (RN) - Heritage Valley LTACH

Director of Quality Management (RN)

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The Director of Quality Management is responsible for the management of efficient, cost effective operations of the performance improvement functions for the assigned PAM Health hospital(s). Coordination with hospital and medical staff leadership to foster a culture of safety by coordinating the design, measurement, assessment, and planning activities to improve patient care and organization functions. Serves as a liaison with accrediting and regulatory bodies such as TJC, CIHQ, CMS, and Department of Health. Provides direction and assistance to the medical staff regarding medical staff quality measures.

Quality Management

• • Monitors adherence to compliance for assigned hospital(s) and reports to the Hospital CEO.
  • Develops and/or maintains reporting systems to provide timely information to administration regarding compliance status with guidelines, rules/regulations and internal policies and procedures. Works with staff so that a systematic process for monitoring and reporting is timely and appropriate
  • Maintains knowledge of state, federal, and local laws and regulations that impact hospital/clinic operations. Demonstrates a working knowledge of accreditation requirements, especially TJC and CIHQ. Works to ensure the readiness of hospital /clinic for accreditation surveys and other compliance inspections. Develops and maintains systems for ensuring compliance with laws, rules, regulations and accreditation requirements.
  • Systematically performs on-site surveillance inspections with the Safety Officer and Infection Control personnel in the hospital for the purpose of validating compliance with codes and standards.
  • Coordinates implementation of the hospital’s performance/outcomes improvement plan, consistent with system-wide QAPI plans
  • Collects, analyzes, evaluates, and appropriately reports data relative to performance improvement for inpatient and outpatient facilities throughout the region. Notes trends as they appear and makes appropriate recommendations when opportunities to improve patient care arise. Regularly reports to administration, assigned committees, locally and at the corporate level.
  • Serves as chairman for the hospital QAPI committee. Assures all minutes and reports of assigned committees are complete and available in a timely manner.
  • Serves as a resource to QAPI teams and department managers in performance improvement process techniques and external agency standards. Facilitates QAPI team meetings, when appropriate, and ensures timely follow-up and reporting.
  • Manages the occurrence monitoring system and ensures timely investigation of incidents to minimize risk to the hospital; keeps Corporate Risk Manager appraised of significant issues in the hospital(s) assigned.
  • Serves as co-chair of the Environment of Care (EOC) committee.
  • Prepares agenda and minutes for meetings for QAPI, and collaborates with the co-chair of EOC.
  • Assists with data collection and ensures overall data collection and score card compliance.
  • Annually reviews /evaluates policies and QAPI plan in conjunction with home office.
  • Responsible for restraint education
  • Facilitates the development of the post survey Plan of Correction.
  • Manages the patient satisfaction program; assures that patient complaints are heard and acted upon in a timely fashion to maximize satisfaction and minimize risk.

Medical Staff QAPI Resource

• • Serves as resource to hospital’s medical staff on compliance and performance/outcomes improvement activities.
  • Assists medical staff in development of compliance and QAPI monitors. Makes recommendations to the Medical Executive Committee and to other appropriate medical staff committees.
  • Provides quality input for the Medical Staff and Medical Executive Committee meetings. Coordinates staff input and follow-up for all items of committee business. Ensures recommendations are communicated and actions are recorded in committee minutes
  • Conducts periodic compliance reviews of applications for medical staff privileges, ensuring completeness and compliance with standards such as Medical Staff Bylaws, TJC, CIHQ, and Medicare.
  • Collects data for the ongoing professional practice evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) of medical staff.

Leadership

• • Inclusiveness: Promotes cooperation, fairness and equity; shows respect for people and their differences; works to understand perspectives of others; demonstrates empathy; brings out the best in others and in his/her team.
  • Managing Staff: Coaches, evaluates, develops, and inspires staff. Sets expectations. Recognizes achievements. Effectively manages conflict. Aligns dept. goals with company goals. Provides feedback, group leadership. Delegates appropriately. Evaluations completed on time.
  • Stewardship and Resource Management: Demonstrates accountability and sound judgment in managing company resources. Appropriate understanding of confidentiality and company values. Adheres to and supports company policies, procedures and safety guidelines.
  • Problem-Solving: Identifies problems, involves others in seeking solutions. Conducts appropriate analysis. Searches for best solutions. Effectively and efficiently implements appropriate response to correct problem. Responds promptly and effectively to new challenges
  • Decision-Making: Makes clear, consistent decisions. Acts with integrity in all decisions. Distinguished relevant from irrelevant information. Makes timely, appropriate decisions.
  • Strategic Planning and Organizing: Understands company vision and aligns priorities accordingly. Measures outcomes. Uses feedback to redirect as required. Evaluates Appropriately organizes complex issues to desirable resolution.
  • Communication: Connects with peers, subordinate employees and all customers. Actively listens. Clearly and effectively shares information. Demonstrates effective oral and written communication skills. Negotiates effectively
  • Quality Improvement: Strives for efficient, effective, high quality performance in self and the department. Delivers timely and accurate results. Resilient when responding to matters that are challenging. Takes initiative to make improvements.
  • Leadership: Motivates others. Accepts responsibility. Maintains high morale in department. Develops trust and credibility. Expects honest and ethical behavior of self and staff.
  • Teamwork: Encourages cooperation and collaboration. Builds effective teams. Works in partnership with others. Is flexible. Responsive to the needs of others.
  • Development: Maintains up-to-date skills through involvement with professional organizations or continuing education.

Customer Service

• Maintains the highest level of customer service via courtesy, compassion and positive communication.
  • Promotes the Mission and Vision of PAM Health within the work environment and community.
  • Respects dignity and confidentiality by adherence to all applicable policies and procedures.

Health and Safety

• • Works in a manner that promotes safety; wears clothing appropriate to the performance of the job.
  • Participates in OSHA required training.
  • Follows universal precautions as appropriate for position; complies with Employee Health requirements for continued employment.
  • Reports unsafe practices to management.
  • Knows own role in case of an emergency.

Infection Control Responsibilities

• • Assures coordination of the hospital-wide infection control program consistent with the policies, procedures, and guidelines of PAM Health.
  • Initiates the evaluation of hospital-wide infection control plan.
  • Assures monitoring for compliance with hospital-wide infection control related policies and procedures and regulatory body requirements.
  • Assures monitoring of infectious diseases present in the hospital population, mode of transmission, and recommended treatment.
  • Assists with education of all employees regarding handwashing, standard precautions, and other appropriate infection control related information.
  • Participates in hospital educational programs on health, safety, hazardous waste, etc.
  • Assures appropriate reporting activities are completed.

POSITION QUALIFICATIONS

Education and Training: Current licensure as a Registered Nurse (RN) in the State where the hospital resides. Current BLS certification required.

Experience: Minimum of five years current clinical experience required. Prior quality management experience preferred.

Knowledge, Skills, and Abilities:

• Ability to effectively express ideas and views when speaking to groups, hospital managers and staff, and patients/family members.
• Clerical ability to write reports, memorandums, etc.
• Cognitive ability to gather and analyze data and prepare reports.
• Numerical ability to evaluate statistical data and to make various computations in planning departmental operations and budgets.
• Organizational ability to direct and motivate professional and non-professional staff in performance of all activities.
• Strong leadership and management skills and a high level of initiative for creative problem-solving.
• Capacity to relate to people in a manner to win confidence and establish rapport.
• Organizational skills to prioritize work and use time effectively with flexibility to adjust to changing priorities and the various details of the job.

ABOUT US

PAM HEALTH (PAM) based in Enola, Pennsylvania, provides specialty healthcare services through more than 70 long-term acute care hospitals and physical medicine and rehabilitation hospitals, as well as wound clinics and outpatient physical therapy locations, in 17 states. PAM Health is committed to providing high-quality patient care and outstanding customer service, coupled with the loyalty and dedication of highly trained staff, to be the most trusted source for post-acute services in every community it serves. Its mission is to serve people by providing compassionate, expert care, and to support recovery through education and research.

Joining our PAMily allows you to work in a collaborative environment with colleagues and leadership with exposure to a variety of patient care levels. Aside from our competitive pay, generous paid benefit time, and excellent insurance options, you will also have opportunities for professional growth through our Education Advancement Program.

We are excited to learn more about you and hope that you consider joining us on a shared mission to improve the lives of others by being an integral part of our We Care Program. Please take a moment to visit us online at www.PAMHealth.com for a comprehensive look at how we're able to positively impact our local communities.

PAM Health does not discriminate and does not permit discrimination, including, without limitation, bullying, abuse or harassment, on the basis of actual or perceived race, color, religion, national origin, ancestry, age, gender, physical or mental disability, sexual orientation, gender identity or expression or HIV status, or based on association with another person on account of that person's actual or perceived race, color, religion, national origin, ancestry, age, gender, physical or mental disability, sexual orientation, gender identity or expression or HIV status.