Director of Quality Assurance

Job Description

Job Description

PLEASE NOTE - This position may require temporarily relocation to other TONHC Facilities: Sells Hospital, Santa Rosa Health Center, San Simon Health Center, and San Xavier Health Center. Position Summary:

Responsible for planning, developing, directing and evaluating the Hospital's quality assurance/performance improvement (QAPI) programs and initiatives.

Scope of Work:

This position is located at the Tohono O'odham Nation Health Care (TONHC), Sells Hospital, which is located at Sells, Arizona and provides oversight of QAPI program at all four facilities; Sells Hospital, San Xavier HC, Santa Rosa HC and San Simon HC. Provides direct oversight and supervision to the following programs: Infection Control, Safety/Emergency Management, Utilization Review, Compliance, Risk Management, Patient Experience and Employee Health.

Essential Duties and Responsibilities:

• Establishes, reviews, and coordinates Performance Improvement (PI) Plans for Tohono O'odham Nation Health Care and related interdisciplinary workgroups and teams.
• Monitors TONHC for compliance with The Joint Commission and CMS guidelines by reviewing and maintaining reports by attending the various hospital standing committee meetings and department meetings, and conducts reviews of charts, records, and procedures.
• Analyzes the organizational climate periodically to determine the needs of employees and patients, which forms the basis of the internal and external customer relations and staff satisfaction programs.
• Identifies measures or indicators of system performance and the actions needed to improve or correct performance relative to the goals of Implements scientific rules and methods to solve problems.
• Identifies, investigates, and coordinates the resolution and follow-up of problems involving the quality and appropriateness of patient care.
• Performs tracer methodology reviews as recommended by the Joint Commission through the utilization of nursing skills.
• Reviews and assesses the type of care, treatment, and services provided to patients and the appropriateness of care.
• Present formalized reports with data to Governing Body, TONHC Leadership, Chief Nurse Executive, Leadership Committee, and Medical Staff members with recommendations required by The Joint Commission.
• Takes steps to ensure that health care programs are designed and are administered in such a manner to correct deficiencies and optimally utilize all available resources.
• Works with all departments to assist with developing and reviewing PI plans/reports and data collection.
• Assists staff to make data-driven decisions using performance improvement methodologies.
• Prepares periodic status reports for the Hospital's Leadership Committee and Governing Body to include an annual evaluation of the effectiveness of the Hospital's Quality Assurance/Performance Improvement program.
• Provides orientation, in-service training and technical assistance to each Department on QAPI program methodologies and requirements.
• Develops and maintains the Performance Improvement/Risk Management resource and information center.
• Develops mechanisms for data tracking to follow trends, variances, and "fall-outs" inpatient care and administrative processes.
• Assesses the interrelationships among disciplines and service/programs to ensure compliance and competence to enforce the standards of care, treatment, and services provided by TONHC.
• Exercises independent decision-making processes to identify, plan, and execute patient care improvements throughout the organization.
• Delivery of successful outcomes as a result of good planning and execution and spreads change throughout the organization.
• Works on the front line as a coach and mentor in or to achieve and maintain successful changes.
• Initiates, develop, maintains, and evaluates the TONHC Risk Management system, which reduces adverse occurrences of potentially compensable events.
• Ensures TONHC patient complaints logs are maintained and ensures timely follow-up with appropriate staff for a resolution of the complaint.
• Recommends appropriate avenues of action to ensure maximum health and safety for patients, employees, and visitors through established policies, procedures, and coordinating efforts with QAPI team members.
• Monitors and ensures ongoing staff development and education regarding Risk Management processes (CMS Compliance, Privacy Act, EMTALA, etc.) are implemented.
• Ensures all data, statistics, reports, and other risk management documents are appropriately governed by the Privacy of Freedom of Information Acts and different patient confidentiality rules and regulations.
• Review, coordinate and report data to the Leadership Team, Performance Improvement Team, and Governing Body.
• Chairs assigned committees related to performance improvement and strategic planning and participate on other standing committees as assigned.
• Works with the Chief Medical Officer and Compliance Officer in monitoring and tracking Tort claims.
• Recommends root cause analyses when appropriate.
• Assists medical and nursing staff in conducting mock exercises, including Code Blue exercises using nursing skills and assists with documentation and training.
• Ensures TONHC to include the hospital and the three (3) health care centers substantially comply with the Joint Commission Accreditation Standards.
• Conducts audits to ensure compliance with The Joint Commission Standards and uses independent judgment to cease services if it presents a risk to patient care.
• Works in concert with key clinical and other Leadership staff to ensure patient and employee of employees.
• Supervise the work of employees.
• Implements overall Quality Assurance/Performance Improvement Plan and Patient Advocacy programs and plans accordingly to satisfy the hospital's varying requirements, priorities, and objectives.
• Determines staff and other resources necessary for program operations and makes adjustments among subordinate units as deemed appropriate.
• Establishes or approves overall work schedules and determines individual and group work assignments.
• Conducts meetings and conferences with subordinate staff to explain work requirements, methods, and procedures.
• Formulates and issues written instructions and procedures for non-routine and complex assignments.
• Reviews, modifies, approves, or rejects changes in functions, procedures, and other matters proposed by subordinates.
• Makes decisions on problems not covered by precedents, protocols, or established policies.
• Reviews and analyzes records, reports, and other data to track the department's progress in achieving QAPI objectives and goals.
• Recommends disciplinary actions involving supervised employees.
• Approves, modifies, or rejects career development plans, training requests, employee utilization proposals, and related personnel. Approves or disapproves all leave requests for employee supervised.
• Demonstrates sensitivity to the development needs of all employees; seeks out and utilizes all available resources in carrying out the EEO compliance.
• Performs Administrative Call when assigned.
• Develops and executes departmental budgets.
• Other job-related duties assigned.

Knowledge, Skills, and Abilities:

• Knowledge of the Tohono O'odham culture, customs, and traditions.
• Professional knowledge in clinical nursing is pertinent to hold this position.
• Knowledge of the Tohono O'odham Nation's mission, organization, programs, and requirements of a health care delivery system to coordinate and interface the Employee Orientation, Staff Development, and Education Services Programs with all departments of the Hospital and meet the need of management and employees.
• Knowledge of hospital self-assessment programs, accreditation requirements, including quality assurance, risk management, safety/infection control, utilization review, and Medicare compliance.
• Knowledge of governmental and nationwide regulations and standards, which deal with the various regulatory and credentialing groups, and an ability to apply and reconcile requirements in preparing recommendations and in coordinating this program.
• Knowledge of data analysis and collection techniques to collect and analyze data, identify problems and trends, establish priorities on major issues, make recommendations on utilizing appropriate resources.
• Must have knowledge and ability to appropriately utilize, implement, supervise, and teach the use of electronic data collection.
• Knowledge of the various functions/departments within the Hospital and motivations of varied employees and groups to effectively communicate with each other to gather information, present recommendations, and coordinate program services.
• Knowledge of health and educational resources.
• Knowledge of and skill in using personal computers, various software, and related computer equipment is required to maintain databases, prepare reports, and track program activities.
• Knowledge of Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 (HIPAA).
• Knowledge of interpersonal skills and ability to establish coordination with the medical staff to effect change or meet regulatory requirements for TONHC.
• Knowledge of pathophysiology of disease entities. Advanced understanding of current scientific nursing theories, procedures, and techniques used in the care and treatment of all types of patients.
• Knowledge and ability to recognize deviation from the normal to institute health services appropriately and safely.
• Ability to travel as required within the course of work assignments.

Minimum Qualifications:

• Master's Degree in Health Care Administration, Nursing or Business Administration and;
• Degree or diploma from a professional nursing program approved by the legally designated State-accrediting agency at the time the applicant completed the program and;
• Four years of experience, education, or training, involving principles, techniques, and accepted practices of quality assurance/performance improvement work preparation of technical reports regarding quality assurance/performance improvement issues, identifying specific problem areas and provides recommendations for corrective action and;
• Three years of supervisory experience.

Licenses, Certifications, Special Requirements:

• Must have active, current, and unrestricted license as a professional registered nurse in a State, District of Columbia, the Commonwealth of Puerto Rico, or a territory of the United States and;
• Must have current certification in Healthcare Cardio Pulmonary Resuscitation (CPR), Automated External Defibrillator (AED).
• Upon recommendation for hire, a criminal background and a National FBI fingerprint check are required to determine suitability for employment, including a 39-month driving record.
• May require possessing and maintaining a valid driver's license (no DUIs or major traffic citations within the last three years).
• If required, must meet the Tohono O'odham Nation tribal employer's insurance requirements to receive a driver's permit to operate program vehicles.
• Based on the department's needs, incumbents may be required to demonstrate fluency in both the Tohono O'odham language and English as a condition of employment.

Physical Demands:

While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to sit; walk; use hands to finger, handle, or feel, reach with hands and arms. The employee must occasionally lift and move up to 30 pounds.

This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all- inclusive.