Dir. Quality Management
CHRISTUS Central Louisiana/St. Frances Cabrini
CHRISTUS St Frances Cabrini-40100
3330 Masonic Dr
Alexandria, LA 71301
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Directs and facilitates the following functions: Medical Staff Services and Credentialing, Facility and Medical Staff Performance Improvement, Regulatory Readiness, Public Reporting of Healthcare Measures, Performance Measurement System, Physician Advisors, Infection Control, Risk Management and Patient Safety. Provides support to the Physician Satisfaction and Customer Satisfaction survey processes. Provides guidance to CHRISTUS Central Louisiana Region facilities on the above functions. Performs assigned tasks in accordance with the hospital's philosophy, values, standards, policies and procedures.
Drives Results -- Consistently achieving results, even under tough circumstances.
Manages Conflict -- Handling conflict situations effectively, with a minimum noise.
Communicates Effectively -- Developing and delivering multi-mode communications that convey a clear understanding of the
unique needs of different audiences.
Directs Work -- Providing direction, delegating, and removing obstacles to get work done.
Builds Effective Teams -- Building strong-identity teams that apply their diverse skills and perspectives to achieve
Business Insight -- Applying knowledge of business and the marketplace to advance the organization's goals.
Ensures Accountability -- Holding self and others accountable to meet commitments
Goals -- Completes quarterly goals
Delivering the Mission -- Performs duties as defined in this job description and demonstrates mastery of role
DIRECT ACTIVITIES OF MEDICAL STAFF SERVICES AND CREDENTIALING (10%)
Supervise and provide direction to the Medical Staff Coordinator and Secretary.
Attend Medical Staff meetings, with oversight of agenda material, minutes and required follow up.
Direct activities of Medical and Allied Health Staff appointments and reappointments.
Oversee regulatory compliance with privileging formats.
Facilitate flow of physician specific performance improvement data to the Medical Staff.
Facilitate appropriate review and revision of Medical Staff Bylaws, Rules and Regulations and Medical Staff Policy additions or revisions.
Responsible for TJC Medical Staff Chapter compliance.
DIRECT ACTIVITIES OF QUALITY MANAGER (20%)
Provide oversight of facility wide performance improvement activities.
Provide oversight of medical staff performance improvement activities.
Provide oversight of performance measurement.
Coordinate PI Council meetings with incorporation of safety, quality and customer satisfaction initiatives.
Present appropriate PI information to the PI Committee of the Regional Governing Board.
Coordinate flow of PI information throughout the appropriate governing levels.
Responsible for TJC Performance Improvement chapter compliance, including Medical Staff monitoring functions.
FACILITATES AND COORDINATES THE ONGOING HOSPITAL-WIDE JOINT COMMISSION PREPAREDNESS ACTIVITIES. (45%)
Develops and maintains ongoing TJC compliance plan, with appropriate input and effective communication to all appropriate levels within the organization.
Acts as liaison between the hospital and TJC.
Completes TJC survey application, coordinates TJC survey agenda and scheduling.
Facilitates mock survey process, coordinating agenda and scheduling of review sessions.
Coordinates all education related to TJC compliance.
Serves as Chairperson of Regulatory Readiness Committee.
Facilitates all aspects of the Regulatory Readiness Committee, planning agendas and tracer surveys.
PROVIDES OVERSIGHT TO THE CHRISTUS CENTRAL LOUISIANA REGION FOR REGULATORY PREPAREDNESS AND COMPLIANCE ACTIVITIES. (5 %)
Develops and maintains relationships with regional facility leadership staff.
Provides assistance and oversight to regulatory readiness and compliance.
Provides feedback to Chief Executive Officer regarding regulatory compliance of regional facilities.
DIRECTS ACTIVITIES OF NOSOCOMIAL INFECTION PREVENTION (10%)
Supervise and provide direction to Infection Control Coordinator and Nurse.
Oversee program for prevention of nosocomial infections.
Responsible for TJC Infection Prevention and Control Chapter compliance
DIRECTS ACTIVITIES OF RISK MANAGEMENT AND SAFETY (10 %)
Supervise and provide direction to Risk Management and Safety Coordinator
Coordinate risk prevention and claims management activities and incorporate into performance improvement processes.
Oversee Safety and Disaster Preparedness program
Baccalaureate or Associate Degree in a health care related field
Five years' experience in a hospital setting. Three years supervisory experience, with experience preferred in the Quality field.
Must possess excellent communication, organizational and human relation skills. Must have flexibility in dealing with changing job demands. Must have the ability to relate in a positive, productive, and professional manner. Must be proficient in word processing and spreadsheet software. Must interact on a professional level with physicians and other hospital staff and be able to handle requests and complaints from them.
Current licensure per related health care field