Provide leadership for planning, management, implementation, integration and coordination of the Quality Department and Medical Staff Services in support of facility goals dedicated to excellence, effective leadership, and financial stability. The Quality Department includes Infection Control, Joint Commission, CMS compliance, Core Measure Abstraction, and Medical Staff peer review and quality oversight, as well as facility wide performance improvement and quality oversight. The VP of Quality & Compliance supports the delivery of the high quality, cost effective patient care through activities based on facility strategic goals and objectives.In this role, you will:Directs development of specific short and long-range programs and project plans to obtain the facility objectives.Responsible for the planning and coordination of the Quality Department and Medical Staff Office functions, the operational efficiency and effectiveness as well as major impact on all other hospital areas. Participates and facilitates Performance Improvement activities using CRMSs process improvement methodology PDSA.Effectively interviews and selects a qualified number of personnel as required to meet department objectives. Ensures hiring practices conform to appropriate Affirmative Action/EEO practices and regulations.Provides direction to the staff of the Quality department and Medical Staff Office. Reviews performance of the departments staff and approves staff evaluations. Responsible for appropriate disciplinary action of staff members as needed.Oversees the prioritization of projects and directs resources to ensure the attainment of facility goals.Responsible for ensuring the department meets and adheres to all applicable federal, state, Joint Commission and local regulatory agency requirements and for ensuring the department and facilities success in any regulatory survey. Coordinates training and process for Survey readiness including tracers, identification of deficiencies and oversight of action plans for improvement.Participates on various committees and other task forces as may be established by management to plan, organize and drive the facility.Directs and/or participates in regular discussions and reviews on a variety of diverse/complex issues including financial and administrative matters, which have hospital-wide impact.Responsible for making decisions required to maintain acceptable operations based on strategic goals and policies. Displays ingenuity and foresight in determining the most appropriate solution in the absence of established guidelines.Confers with other department directors when necessary to resolve procedural difficulties, clarifying department responsibilities, objectives and resolving identified problems.Responsible for special projects as assigned by the Administrative Management Team. Meets all objectives as set forth in individual evaluation and displays a good work attitude towards job responsibilities.Adheres to hospital/departmental attendance policy, work hours and maintenance of personal appearance as stated in facility policy.Ensures sound hand hygiene is fostered by education, measurement and intervention, to ensure improved outcomes related to the spread of infections by poor hand hygiene.Ensures risk reductions occur for hospital acquired adverse ventilator events by working with the organizations Risk Management Staff, Infection Control Practitioner, Critical Care leadership and Respiratory Care leadership to foster improvement in ventilator care by education, measurement and intervention as findings indicate.
