Facilitates and coordinates hospital wide quality management programs to ensure compliance with Joint Commission and other regulatory requirements. Facilitates compliance with core measures. Facilitates Hospital Patient Safety/Quality Council meetings. Prepares and presents quality reports for Medical Executive Committee and Hospital Governing Board. Facilitates hospital risk management activities to include root cause analysis as required. Responsible for hospital complaint and grievance process. Manages hospital occurrence reporting process. Prepares and presents complaint and occurrence analysis reports for Hospital Quality Council, Medical Executive Committee and Governing Board. Coordinates Medical Staff Peer Review process. Develops and manages the department budget.
1. Analyze complex situations to identify opportunities for improvement using data-driven decision making
2. Assist departments in the development, implementation, and monitoring of performance and outcomes measurement.
3. Prioritize projects based on the organization's strategic quality goals.
4. Develop strategies to implement projects.
5. Manage projects, including department resource allocation and team development.
6. Uses analytical skills for improving patient safety and enhancing the quality of patient care.
7. Performs root cause analysis and benchmarks data from outside sources to improve patient safety.
8. Provides written and graphical reports to appropriate committees on a monthly basis.
9. Follows protocol to protect the assets of the hospital.
10. Presents risk management issues and reports and keeps administration informed of risks in a timely manner.
Bachelor’s degree in nursing is required
Master’s degree in a health related field is preferred
Registered Nurse in North Carolina is required (or compact state)
CPPS and/or CPHQ desirable
American Heart Association BLS is required
Minimum of 5 year experience in integrated case management, quality management, change management, or outcomes management