The Executive Director Quality, Infection Prevention and Regulatory Preparedness is responsible for providing strategic leadership and direction in all quality, patient safety, regulatory compliance, and infection prevention for the organization ensuring safe patient care.
PRIMARY DUTIES AND RESPONSIBILITIES:
Directs collaborative efforts with physicians, revenue cycle, payers, patients, and their families, to incorporate evidence-based practices and appropriate use of resources.
Accountable to ensure the hospital maintains adherence to all regulatory requirements. Manages regulatory site surveys, creates plans of correction as needed, and ensures compliance to plans of correction.
Coordinates, evaluates, updates, and disseminates all data and educational information as it relates to regulatory bodies such as the Joint Commission and Massachusetts Department of Public Health (DPH).
Manages all data and reporting for quality metrics and creates improvement plans to increase publicly reported ratings such as Leap Frog and Star Ratings. Manages submissions as needed (Ex: Leap Frog)
Facilitates the Performance Improvement and Patient Safety Committee.
Coordinates the medical staff quality programs.
Communicates effectively with Hospital leadership in the development of day-to-day and strategic goals.
Ensure that appropriate departments are updated regarding new standards, policies, and procedures.
Oversees all National Patient Safety Goals (NPSG) implementation and ongoing compliance.
Establish a coordinated tracer methodology ongoing process and will periodically perform tracers.
Facilitates Failure Modes and Effects Analysis (FMEA's) for the organization.
Promotes an environment of transparency with employees and nursing department.
Actively participates in review and identification of opportunities of nurse quality indicators as measured by The National Database of Nursing Quality Indicators (NDNQI) at individual department level collaborating with nurse managers.
Benchmarks performance against national best practices.
Financial stewardship: monitors, controls, and is accountable for maintaining departmental costs within budgeted allocations.
Must be able to manage multiple competing priorities and maintain calm demeanor in stressful environment.
Proficiency with computers and clinical applications.
Ability to effectively negotiate with patients, families, internal and external providers of patient care services.
Consistently provides service excellence to all patients, family members, visitors, volunteers, and co-workers.
Challenges current working practices, identifies process improvement opportunities and presents recommendations and solutions to management. Engages and commits to the organization's culture of continuous improvement by actively participating, supporting, and promoting CCHC Pillars of Excellence.
EDUCATION/EXPERIENCE/TRAINING:
BSN degree or equivalent education and years of experience, Master's degree in nursing (MSN) or related field (MBA/MHA) preferred
MA State Registered Nurse License
Certified Professional in Healthcare Quality (CPHQ) is preferred.
Minimum of five (5) years in Performance Improvement/Quality Management and Infection Prevention.
Provided leadership for at least 2 successful joint commission surveys utilizing tracer methodology.
Working knowledge of regulatory agency standards and requirements
Must possess excellent oral, written and analytical skills. Effective problem solving, conflict management and organizational skills.
Clinical competence and the ability to establish respect and rapport with peers, staff, physicians, and administration within Cape Cod Healthcare.
Schedule Details: Full time, Monday-Friday, occ. eves, weekends, and holidays