Director of Quality Assurance

Job Description

Job DescriptionPLEASE NOTE - This position may require temporarily relocation to other TONHC Facilities: Sells Hospital, Santa Rosa Health Center, San Simon Health Center, and San Xavier Health Center.Position Summary:

Responsible for planning, developing, directing and evaluating the Hospital's quality assurance/performance improvement (QAPI) programs and initiatives.

Scope of Work:

This position is located at the Tohono O'odham Nation Health Care (TONHC), Sells Hospital, which is located at Sells, Arizona and provides oversight of QAPI program at all four facilities; Sells Hospital, San Xavier HC, Santa Rosa HC and San Simon HC. Provides direct oversight and supervision to the following programs: Infection Control, Safety/Emergency Management, Utilization Review, Compliance, Risk Management, Patient Experience and Employee Health.

Essential Duties and Responsibilities:

• Establishes, reviews, and coordinates Performance Improvement (PI) Plans for Tohono O'odham Nation Health Care and related interdisciplinary workgroups and teams.
• Monitors TONHC for compliance with The Joint Commission and CMS guidelines by reviewing and maintaining reports by attending the various hospital standing committee meetings and department meetings, and conducts reviews of charts, records, and procedures.
• Analyzes the organizational climate periodically to determine the needs of employees and patients, which forms the basis of the internal and external customer relations and staff satisfaction programs.
• Identifies measures or indicators of system performance and the actions needed to improve or correct performance relative to the goals of Implements scientific rules and methods to solve problems.
• Identifies, investigates, and coordinates the resolution and follow-up of problems involving the quality and appropriateness of patient care.
• Performs tracer methodology reviews as recommended by the Joint Commission through the utilization of nursing skills.
• Reviews and assesses the type of care, treatment, and services provided to patients and the appropriateness of care.
• Present formalized reports with data to Governing Body, TONHC Leadership, Chief Nurse Executive, Leadership Committee, and Medical Staff members with recommendations required by The Joint Commission.
• Takes steps to ensure that health care programs are designed and are administered in such a manner to correct deficiencies and optimally utilize all available resources.
• Works with all departments to assist with developing and reviewing PI plans/reports and data collection.
• Assists staff to make data-driven decisions using performance improvement methodologies.
• Prepares periodic status reports for the Hospital's Leadership Committee and Governing Body to include an annual evaluation of the effectiveness of the Hospital's Quality Assurance/Performance Improvement program.
• Provides orientation, in-service training and technical assistance to each Department on QAPI program methodologies and requirements.
• Develops and maintains the Performance Improvement/Risk Management resource and information center.
• Develops mechanisms for data tracking to follow trends, variances, and "fall-outs" inpatient care and administrative processes.
• Assesses the interrelationships among disciplines and service/programs to ensure compliance and competence to enforce the standards of care, treatment, and services provided by TONHC.
• Exercises independent decision-making processes to identify, plan, and execute patient care improvements throughout the organization.
• Delivery of successful outcomes as a result of good planning and execution and spreads change throughout the organization.
• Works on the front line as a coach and mentor in or to achieve and maintain successful changes.
• Initiates, develop, maintains, and evaluates the TONHC Risk Management system, which reduces adverse occurrences of potentially compensable events.
• Ensures TONHC patient complaints logs are maintained and ensures timely follow-up with appropriate staff for a resolution of the complaint.
• Recommends appropriate avenues of action to ensure maximum health and safety for patients, employees, and visitors through established policies, procedures, and coordinating efforts with QAPI team members.
• Monitors and ensures ongoing staff development and education regarding Risk Management processes (CMS Compliance, Privacy Act, EMTALA, etc.) are implemented.
• Ensures all data, statistics, reports, and other risk management documents are appropriately governed by the Privacy of Freedom of Information Acts and different patient confidentiality rules and regulations.
• Review, coordinate and report data to the Leadership Team, Performance Improvement Team, and Governing Body.
• Chairs assigned committees related to performance improvement and strategic planning and participate on other standing committees as assigned.
• Works with the Chief Medical Officer and Compliance Officer in monitoring and tracking Tort claims.
• Recommends root cause analyses when appropriate.
• Assists medical and nursing staff in conducting mock exercises, including Code Blue exercises using nursing skills and assists with documentation and training.
• Ensures TONHC to include the hospital and the three (3) health care centers substantially comply with the Joint Commission Accreditation Standards.
• Conducts audits to ensure compliance with The Joint Commission Standards and uses independent judgment to cease services if it presents a risk to patient care.
• Works in concert with key clinical and other Leadership staff to ensure patient and employee of employees.
• Supervise the work of employees.
• Implements overall Quality Assurance/Performance Improvement Plan and Patient Advocacy programs and plans accordingly to satisfy the hospital's varying requirements, priorities, and objectives.
• Determines staff and other resources necessary for program operations and makes adjustments among subordinate units as deemed appropriate.
• Establishes or approves overall work schedules and determines individual and group work assignments.
• Conducts meetings and conferences with subordinate staff to explain work requirements, methods, and procedures.
• Formulates and issues written instructions and procedures for non-routine and complex assignments.
• Reviews, modifies, approves, or rejects changes in functions, procedures, and other matters proposed by subordinates.