Job Description

Overview

West Gables Rehabilitation Hospital

*A joint venture with Select Medical*

Location: Miami, FL

$10,000 Sign-on Bonus

Director of Quality Management (DQM)

Responsibilities

Position Summary

Coordinates the Medical Quality Management and Performance Improvement activities to measurably enhance the quality, process and cost effectiveness of patient and customer services rendered. Coordinates the Performance Improvement and Patient Safety programs in accordance with the guidelines and regulatory requirements of Federal and State regulations on a hospital-wide basis. Oversees operations of the Infection Control and Employee Health Programs. Develops and Reviews policies and procedures to ensure compliance with all regulatory and accrediting standards. Collects data to monitor compliance and/or trends.

• Institutes and monitors the Hospital’s CQI Processes, utilizing data analysis measuring tools. Oversight/coordination of operations of the Infection Control & Employee Health Program based upon hospital size and configuration.
• Assists with the design and compliance of quality processes/activities in the areas of clinical/medical staff PI for all applicable clinical/medical TJC /CARF/DOH standards. Assists with all assigned activities to assure that the hospital maintains accreditation, certification and licensure. Assumes leadership with the Joint Commission and DOH as well as other regulatory agencies with regard to CQI activities.
• Serves as a resource for all departments within the facility to provide guidance on designing, implementing, analyzing and reporting on Quality Improvement.
• Assists clinical areas in developing criteria, monitoring and reporting mechanisms and action documentation related to the hospital’s CQI program.
• Performs basic chart review activities with appropriate staff for outcome utilization, infection control and medical CQI indicators. Analyzes results of chart review activities with appropriate staff and confers with department staff on any case requiring special attention.
• Prepares analysis of significant PI findings pertaining to adverse drug reactions, drug usage evaluation, medical management of acute transfers and other CQI indicators.

Qualifications

Minimum Qualifications

• Registered Nurse with valid state license. Legacy employees may exist with other clinical licensure.
• Requires experience in at least one of the core areas of responsibility: Quality, Survey Readiness, Risk Management, Infection Control, Employee Health and Education.
• Demonstrates familiarity with accrediting standards, including TJC and CARF preferred.

Preferred Experience

• Previous experience in Quality Improvement, with Statistical Process Control experience and computer skills preferred.
• Demonstrates familiarity with accrediting standards, including JCAHO and CARF preferred.
• Certified Professional in Healthcare Quality (CPHQ) preferred.

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