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Director Quality Mgt

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Job ID R1006225 Type Employee - Full Time Location Marlton, New Jersey Standard Hours 40

Summary:

Establishes and facilitates the implementation of the Virtua Quality Plan and Risk Management Plan at their local facility and any associated licensed services.

Drives the action plans to achieve STAR G&O targets for Quality and Patient Safety.

Assures compliance and continued readiness with all regulatory agencies.

Manages the local resources for the collection of data for Core Measures, JCAHO, NJDHSS, Medical Staff Peer Review and ensure accurate chart documentation that serves as the foundation for APR-DRG’s and other pay for performance initiatives.

Position Responsibilities:

• Accountable for analysis of STAR G&O, quality and patient safety data and leads local clinical, physician, ancillary and operations leaders and staff in the development and implementation of strategies to achieve required results.

• Mentors and coaches unit and department directors in quality and patient safety goals, in analysis of their dashboards and the development of unit based action plans that cascade upward and contribute positively into facility results.

• Responsible for local facility’s active participation in the Virtua Risk Management Program; including review and filing of incident reports, data entry into Peminic System, Safe Medical Device Act, reporting of Sentinel events, reportable events to the NJ DOH, etc.

• Analyzes facility specific results to identify opportunities for risk reduction and the development of successful action plans.

• Leads the local facility in continued readiness for JCAHO and NJ DHSS accreditation and licensing surveys.

• Is an active member on various system councils and system committees to provide input on the development and implementation of new initiatives and processes.

• A local senior leader and a member of Operations Management Group. Takes administrative call.

• Provides twenty-four hour, facility wide accountability for all quality and risk issues.

• Serves as the Chair of the local Quality Council, Code Blue Review Team, Mortality Review Team and other local interdisciplinary committees as appropriate to coordinate and implement quality and safety initiatives based on outcomes.

• Acts as a local expert in the DMAIC cycle, educating and coaching staff, managers and physicians in its use.

• Local expert and role model in STAR Coaching skills for leading and facilitating teams.

• Communicates sentinel, critical or reportable events as appropriate.

• Coordinates root cause analysis by the Virtua Event Review Team drives WWW collaborates with members of the Quality, Risk, Safety Work Group to disseminate information, lessons learned and findings relevant to other parts of Virtua.

• Local expert with current knowledge in JCAHO standards and NJ licensing standards.

• Manages the allocation of resources for the local infection control practitioner(s).

• Collaborates with Chief Infectious Disease Officer and ICP to analyze local infection data and helps develop and implements successful strategies for infection prevention.

• In collaboration with Patient Relations, managers and staff, assists in the development of action plans for the improvement of patient satisfaction.

Position Qualifications Required / Experience Required:

Requires five years of healthcare experience.

Experience in acute care facility and a broad base of knowledge in nursing practice, evidenced based care and management.

Required Education:

Bachelor’s Degree in a health related field.

Master’s degree preferred.

Training/Certifications/Licensure:

RN licensure preferred.

Certification in Health Care Quality required or eligibility to sit for CPHQ Exam.
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  • Mission:

    Virtua helps you be well, get well, and stay well.

  • Vision:

    The trusted choice for personalized health care and wellness.

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