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Leads and oversees a comprehensive, efficient, and integrated hospital-wide Continuous Quality and Performance Improvement (CQPI) program. Uses data collection, analysis, and trending to assess performance; focuses on process and systems improvement; directs risk management and patient safety activities; investigates adverse outcomes; coordinates regulatory/accreditation readiness; and educates staff on CQPI and related quality programs.
Job Responsibility:
Provide leadership and oversight of the organization-wide CQPI program
Measure and assess performance by collecting, analyzing, and trending data to identify opportunities for improvement
Focus on improving processes and systems to drive clinical quality, safety, and operational performance
Direct, facilitate, and report on all aspects of risk management and patient safety
Investigate factors contributing to adverse outcomes and drive process/system changes
Direct the hospital-wide CQPI operations, including record reviews for quality indicators and reporting findings to leadership, Medical Executive Committee, Board of Managers, and other committees
Annually review hospital-wide plans for Infection Control (IC) and CQPI
establish goals and objectives for the coming year
Serve as liaison to local health officials
coordinate inspections and accreditation reviews with state and other regulatory agencies
Perform other duties as assigned
Develops and delivers hospital-wide CQPI education and training
Prepares quality/patient safety reports and dashboards for leaders and committees
Partners with clinical and non-clinical departments to sustain improvements and ensure compliance with applicable standards
Requirements:
Registered Nurse with current state licensure highly preferred
clinical license required
BSN or BS/BA required
Minimum two (2) years in an acute hospital or rehabilitation setting required
prior supervisory experience preferred
Basic Life Support (BLS/CPR) required
certification preferred by APIC (American Practitioners of Infection Control) and NAHCQ (National Association of Health Care Quality)
Data analysis and reporting
CQPI methodologies (e.g., RCA, FMEA, PDSA)
risk management and patient safety facilitation
regulatory/accreditation readiness
effective teaching, communication, and collaboration
Nice to have:
Registered Nurse with current state licensure highly preferred
prior supervisory experience preferred
certification preferred by APIC (American Practitioners of Infection Control) and NAHCQ (National Association of Health Care Quality)
What we offer:
Health (Medical, Dental, Vision) and 401K Benefits for full-time employees
Competitive Paid Time Off
Employee Assistance Program - mental, physical, and financial wellness assistance
Tuition Reimbursement/Assistance for qualified applicants
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