DUTIES AND RESPONSIBILITIES
3.1 Has a deep understanding of the standards, measurable elements and intents of the JCI. Maintains continuous knowledge and understanding of JCIA functions and standards.
3.2 Developing NMCSH Quality Improvement Plan.
3.3 Participating effectively in Implementing & Follow up of Q.I. Plan Activities.
3.4 Orchestrating Quality Improvement Initiatives & Activities Hospital-Wide.
3.5 Serves as a resource to all departments, divisions and units, hospital and ambulatory, and to established committees in all areas relating to Quality Assurance.
3.6 Promotes and facilitates cost-effective resource utilization related to infection control policies and procedures.
3.7 Establishes priorities for investigation of problem areas based on the degree of adverse impact on patient care that can be expected if the problem remains unresolved.
3.8 Develops effective patient care review and evaluation mechanisms and monitors to assure results are achieved.
3.9 Directs implementation and maintenance of technical guidelines and frameworks within which quality of care is evaluated.
3.10 Arranges with Quality Facilitators throughout NMCSH for staff education, variance collection and analysis.
3.11 Establishes system-wide variance database for benchmarking, system improvement opportunities, Length of stay and resource management.
3.12 Provides ongoing assessment and support for continuous quality improvement, quality assurance and risk management for the Hospitals priority programs and support its infrastructure.
3.13 Based on the evaluation of the patient’s medical records identifies concern areas and plans for the improvement.
3.14 Communicates appropriate information from studies and data sources to committees, departments and persons affected by the studies.
3.15 Identifies and shares across the system best practice models and care processes (those, which achieve optimal patient outcomes, enhance patient/family and staff satisfaction, are cost effective and resource appropriate.
3.16 Maintains all necessary records pertinent to the JCI process.
3.17 Facilitates Quality Improvement plan meetings.
3.18 Submits a monthly report of quality activities to the QPS committee.
3.19 Maintains records of policies, procedures, guidelines, forms and other documents and ensures the circulation of current documents and the de-circulation of publish documents.
3.20 Maintains records of all Quality Assurance activities.
3.21 Provides educational and technical assistance to committees and departments in meeting their Quality Assurance objectives.
3.22 Maintains active involvement in all aspects of clinical space design, construction and hygiene.
3.23 Performs administrative responsibilities.
3.24 Justifies need for training in Quality Assurance processes and methods and either works with appropriate groups to initiate training or teaches in areas of expertise.
3.25 Coordinates and monitors all Joint Commission on Accreditation of Hospitals compliance activities and participates in the survey process.
3.26 Mock surveys coordination.
3.27 Do an Annual Evaluation of Quality Improvement Program and submits reports to the QPS committee.
3.28 Develops training/orientation program for key members to facilitate system expansion and standardization.
3.29 Performs miscellaneous related duties as requested by General Manager.
3.30 Use a uniform format and content for planning documents.
3.31 Provide a described planned service of the department.
3.32 Guide the provision of identified services.
3.33 Address the staff knowledge and skills needed to assess and to meet patient needs.
3.34 Coordinate and/or integration of services within and with other departments and services.
4.0 QUALIFICATION, LICENSURE, EDUCATION, EXPERIENCE, SPECIAL SKILLS
4.1 Three years or more in healthcare Quality management positions with demonstrated administrative skills.
4.2 Excellent command of oral and written English.
4.3 Responsibility for own continued professional growth beyond minimum preparation. An understanding of management objectives and the ability to implement a systems approach.
4.4 Knowledge of statistics, data collection, analysis, and data presentation.
4.5 Knowledge of federal laws and regulations, and accreditation standards.
4.6 Excellent interpersonal communication and problem-solving skills.
4.7 Ability to work effectively with Medical Staff, hospital personnel and others.
4.8 Must be well versed with Word and Excel.
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