Quality Management Director - Healthcare jobs in New Mexico

Job Summary and Scope

Responsible for the ongoing development, direction, supervision and administration of the following departments and programs: Quality Management, Core Measures, Regulatory Compliance, Accreditation, Patient Safety, Infection Control, Patient Advocacy, and Data Outcomes Research. Plans, directs, manages and oversees assigned programs and activities for accreditation, regulatory and licensing standards related to the delivery of safe and effective patient care. Responsible for regulatory readiness and overseeing regulatory and accreditation visits ensuring that the appropriate staff and leadership are involved in that process. Investigate and respond to regulatory complaints. Investigate proposed and new patient care regulations and laws and make recommendations working with physician and leadership staff to develop any required and ongoing action plans to address deficiencies. Establish pro-active and ongoing process for areas at risk and communicate to appropriate hospital and physician leadership. Ensure policies and procedures are developed, administered and monitored for efficient, effective management of all programs.

Essential Functions:

• POLICIES AND PROCEDURES - Maintain established departmental policies and procedures, objectives, and quality assurance programs

• PROFESSIONAL DEVELOPMENT - Enhance professional growth and development through participation in educational programs, reading current literature, attending in-services, meetings and workshops.

• Maintains the goals and objects of the Quality Management Department in line with the organization strategic plan.

• Serve as the organization’s primary point of contact to ensure compliance with all federal, state and local laws and regulations governing the licensing and accreditation of the organization.

• Provide direction to the medical staff credentialing process and education process to ensure compliance with HIPPA, medical staff bylaws, TJC, CMS, and NCQA and other regulatory standards and initiatives.

• Supervise and provide direction to the infection control process to ensure compliance with TJC, CMS, NMDOH, OSHA, CDC, NHSN, and other regulatory standards and initiatives.

• Supervise and provide direction with the core measure abstraction and data processes to ensure compliance with TJC and CMS and other regulatory standards and initiatives.

• Effectuates performance evaluations, personnel policies, hiring, promotion and discipline.

• Coordinates quality improvement activities for successful accrediting, licensing, and certification surveys.

• Coordinate activities in collaboration with other divisions, departments and outside agencies and organizations; respond and resolve inquiries and complaints.

• Prepare reports as required: oversee and ensure compliance with quality reporting for all regulatory and licensing bodies by continually monitoring Hospital operations and programs and physical properties; initiate changes as required.

• Demonstrate proactive approach to patient safety by seeking opportunities to improve patient safety through questioning of current policies and processes

• Establish competencies, training sessions, and education programs for hospital personnel. Prepare and present training on clinical quality, Joint Commission, quality improvement and other pertinent subjects.

• Assists Department Directors in development and implementation of operating policies and procedures which reflect quality concerns and ensures interdepartmental policies and procedures concur with one another and meet regulatory requirements.

• Serves as a representative for the hospital within the community as required.

• Maintain competence in part by participation in local, state and national professional organizations.

• Performs miscellaneous job-related duties as assigned.

SRMC Core Values

Integrity: Our words and actions match our values

To Serve: We put the needs of others before our own

Excellence: We strive to exceed expectations and/or standards in every activity, every encounter, and every initiative

Safety/Quality: We provide evidence based care, programs, services, and an environment that achieves the best outcomes

Teamwork: We enjoy the ability and power to work collaboratively to deliver exceptional service

Accountability

• Wide diversity of work situations that involve a high degree of complexity

• Responsible for developing policies and procedures

• Maintain records of a highly confidential nature

• Provide decisions within interpretation of applicable regulatory requirements and governmental guidelines

• Oversee and participate in the development and administration of the division budget; forecast and recommend funds needed for staffing, equipment, materials and supplies

• Accountable for long-range planning

Communication Skills

• Demonstrated high level of professionalism, confidentiality, and judgment

• Must be an articulate and persuasive communicator with outstanding written and presentation skills

Required Qualifications

• Knowledge of organizational structures and processes that support compliance with laws, state and federal regulations and accreditation standards. (CMS, TJC, NMDOH, NCQA, OCR, NHSN, OSHA, CDC, and HIPAA)

• Demonstrated ability to meet multiple deadlines and manage multiple priorities by maintaining a high level of organization.

• Process improvement concepts and tools

• Knowledge and skill in computer software programs for reports, spreadsheets, and presentations.

• Lean Management and/or Six Sigma process improvement skills.

Education/Experience

Education: Bachelor’s degree, with relevant health care work experience

Licenses/Certifications:

Work Experience: 7-10 years directly related experience in a hospital/health care environment

Preferred Educational/Experience Requirements: Registered Nurse, Master's Degree in related discipline

Supervision

• Supervision of various departments

Conditions of Employment

• Must pass a pre-employment criminal background check, reference checks and a post offer drug screen.

• Must be employment eligible as verified by the U.S. Dept. of Health and Human Services Office of Inspector General (OIG) and the Government Services Administration (GSA).

• Hospital required vaccinations

• Hospital required competencies

Working Conditions

• Typical office and/or patient care, acute care hospital environment.

• Must be able to travel locally between facilities and within the surrounding community.

• Occasional exposure to minimal physical risk