Director of Quality

Job Details

Medina Regional Hospital 3100 Ave E - Hondo, TX

Full Time

None

Days

Description

POSITION PURPOSE:

The Quality Director is responsible for overseeing and ensuring the highest standards of quality across all aspects of the organization. This role involves developing, implementing, and maintaining quality management systems, policies, and procedures to ensure compliance with industry standards and regulatory requirements. The Quality Director will lead continuous improvement initiatives, manage quality assurance teams, and collaborate with other departments to drive excellence in product and service delivery. This position aims to enhance customer satisfaction, reduce defects, and promote a culture of quality throughout the organization.

KEY RESPONSIBILITIES:

Organizes, directs, manages, and coordinates various departments, programs, and services related to managing resources, assuring quality services, and patient/staff safety.

Collects, analyzes, and manages real-time performance improvement data.

Coordinates activities and acts as liaison with Professional Review Organization (PRO).

Reviews and recommendations of contracts with PRO, insurance companies, and managed care organizations.

Designs and implements program evaluations of all aspects of resource and quality management.

Develops cooperative relationships with other hospitals and community agencies to pursue goals related to case management, utilization review, and quality care.

Designs and reviews policies and procedures related to quality management such as methods of data collection, outcome performance measures, chart review procedures, case analysis methods, and critical pathways analysis.

Provides consultation, feedback, and recommendations to service providers and staff on resource utilization and adherence to quality standards.

Responds to inquiries related to quality and resource management issues from customers, staff, compliance agencies, and others.

Directs and/or conducts appropriate research into methods to improve utilization of hospital and medical resources and methods to improve patient care.

Compiles statistical data and writes narrative reports summarizing quality management findings.

Directs review of patient records to determine the need for admission and continued stay in hospital.

Directs personnel engaged in quality assurance review of medical records.

Involvement in planning, developing, implementing, and directing nursing services, to work collaboratively, with other interdisciplinary members.

Conducts daily rounds to observe patients and staff, to determine if treatment needs are being met, and to assess if any changes are necessary in the patient’s treatment plan.

Responsible for identifying and evaluating risks to reduce injury to patients, staff members, and visitors within an organization. Work proactively and reactively to either prevent incidents or to minimize the damage following an event.

Perform risk evaluation, make risk-avoiding adjustments to current methods of operation to minimize future risks.

Create and manage effective action plans in response to audit discoveries and compliance violations.

Regularly audit hospitals’ procedures, practices, and documents to identify possible weaknesses or risks.

Ensure all employees are educated in the latest regulations and processes.

Develop internal controls and policies designed to ensure that all compliance needs are met.

Plans, develop, implement, and manage organizations compliance programs. Coordinating with federal and state regulators. Creating and coordinating proper reporting channels for compliance issues.

Provide supervision for quality analyst and employee health/infection preventionist

Other duties as assigned

Qualifications

Current Texas RN license

Bachelor’s Degree

CPR certification

Six months to one-year related experience and/or training; or equivalent combination of education and experience.

Knowledge of QIPP and RAPPS programs is preferred

Certified Professional Healthcare Quality/CPHQ certification is preferred.

Must have proven success in a related role with responsibility for medical staff by-laws, and other accreditation surveys

Demonstrate leadership and managerial ability with Excellent oral and written communication skills. Also, have strong interpersonal skills and a demonstrated ability to work collaboratively.