Directory, Quality, Accreditation and Infection Prevention

Job Summary

This position is responsible for facilitating the hospital Quality Improvement Program, overseeing Infection Control Surveillance Program, mandatory reporting of quality indicators to CMS and State, coordination of medical staff peer review and quality reports, and coordination of compliance with accreditation agency and clinical regulatory standards.

Qualifications

• Bachelor's Degree in relevant field (Required)
• Master's Degree in relevant field (Preferred)

Work Experience

• 3 or more years Quality Improvement, Project Management experience (Required)

Licenses and Certifications

• CPHQ - Certified Professional in Healthcare Quality (Preferred)

Essential Functions

• Lead implementation of the annual Quality Assessment and Performance Improvement (QAPI) plan ensuring the allocation of resources to achieve success.
• Develop comprehensive, strategic and tactical plans to achieve hospital level progress in goal achievement; revise strategic plans accordingly.
• Utilize and foster use of evidence-based medicine to reduce unnecessary variation to standardize care and reduce costs.
• Inspire and guide team members through change while maximizing efficiency and effectiveness.
• Foster a culture of flexibility, innovation, and continuous learning.
• Develop, participate in, and/or lead quality improvement teams/committees; drive the implementation of evidenced based prevention strategies and monitor process and outcome measures toward success.
• Collaborate with others across Phoebe Health System to inspire a system approach where appropriate.
• Stay current on industry trends and best practices to ensure the organization remains at the forefront of quality and safety initiatives.
• Partner with system and hospital leadership to ensure compliance with Federal and state standards and achieve a continual state of readiness.
• Stay abreast of all pertinent federal, state and hospital regulations, laws, and policies.
• Manage regulatory compliance activities including preparation for survey, survey and follow-up documentation, corrective action planning/completion, etc.
• Develop and maintain relationships with regulatory agencies and accrediting bodies.
• Partner with system and hospital leadership to lead a highly reliable organization and achieve a goal of zero harm.
• Engage in and foster a culture of trust and transparency with the aim to reduce errors using just culture principles.
• Conduct and/or lead others in root cause analysis, common cause analysis, failure mode effects analysis (FMEA), proactive risk analysis.
• Ensure compliance with organization’s incident reporting system in a timely and accurate manner.
• Develop comprehensive, strategic and tactical plans to achieve hospital level progress in infection prevention goal achievement; revise strategic plans accordingly.
• Supervise and coordinate hospital infection control surveillance to identify actual nosocomial infections, clustering and outbreaks of infection and infection potentials.
• Plan and provide education and guidance in infection control and prevention measures.
• Ensure compliance with regulatory, accreditation and licensure requirements pertaining to infection control.
• Stay current on industry trends and best practices to ensure the organization remains at the forefront of infection prevention and control initiatives.
• Establish and monitor key performance indicators across the organization.
• Oversee the collection, analysis, assimilation, and reporting of quality data to drive improvement.
• Provide scheduled reports and data to leadership, committees, and external agencies.
• Partner in advancing analytical and technological solutions to improve data integrity and accuracy; standardize quality reporting across the system where applicable.