Rn -Quality Compliance Director

Overall Responsibility:

This position coordinates and manages all QUALITY COMPLIANCE aspects within OneCore Health. The incumbent is responsible for ensuring quality assurance, education, risk management, infection prevention, and performance improvement needs are identified and maintained. Consults with staff, physicians, and other departments on problems and interpretation of OneCore Health's policies and procedures to ensure patient needs and operational efficiency are met. Responsible for identification, recommendations, and implementation of improvement plans and/or preventive measures to ensure ongoing compliance with regulatory standards to ensure safety within the hospital. This position shall lead, facilitate, support, and mentor multidisciplinary teams (including physicians) through the utilization of process improvement methodologies and techniques. The incumbent acts as a change agent to promote process transformation and drives the transition and changes that lead to improved processes and organizational performance. This position is the subject matter expert in process excellence methodologies. Develops curriculum, trains and mentors teams on process improvement methodologies. Facilitates multi-functional teams to develop and execute selected improvement projects.

Key tasks and responsibilities (essential functions)

Quality / Performance Improvement

1. Utilize Six Sigma, Lean, and other continuous improvement methodologies to drive a culture of learning, a dedication to ongoing improvement, and a focus on sustainable results.
2. Develop, maintain and execute Continuous Improvement (CI) plan in conjunction with other members of the leadership team to drive training and activities in support of ongoing improvements to processes and people.
3. Ensure that associated performance management and clinical efficacy metrics aligned with CI activity are reflecting improvement and sustainment when in the control phase.
4. Lead performance improvement events, train and mentor the leadership team and select team members in the principles, methods, and applications of Lean Healthcare techniques such that continuous improvement efforts are integrated into change management processes.
5. Ensure compliance with regulatory boards/state, including, but not limited to Medicare, OSHA, professional organizations such as AORN, AAMI, ASPAN, and the State Health Department in conjunction with the Chief Nursing Officer.
6. Ensure the performance of nursing functions in all areas is according to policy and procedure. Maintain current knowledge of OCH policies and procedures and assist in clinical/quality policy development and review.
7. Accurately identify and expeditiously resolve issues affecting the delivery of patient care services.
8. Develop standards of care and performance for services provided in conjunction with the Chief Nursing Officer and implement a mechanism for the ongoing evaluation and improvement of performance standards.
9. Communicate and report information to the appropriate team members and committees on potential problems, unusual events/occurrences, and changes in any regulatory guidelines or hospital policies that require implementation.
10. Facilitate and actively participate in the Committee of the Whole, Medical Executive Committee, Utilization Management Committee and other designated committees as assigned. Distribute information to clinical staff from each of these committees to ensure a smooth flow of information.
11. Organize all Quality Management meetings, prepare and receive reports, maintain minutes and makes recommendations to the committee based on best practice and current regulatory standards.
12. Establish, update, and/or create forms and other necessary documentation in collaboration with other leaders that is conducive to the needs of the hospital.
13. Collaborate with different departments (radiology, pharmacy, nursing, OR, scheduling, registration) to resolve issues and improve workflow processes throughout the department.
14. Coordinate, facilitate, participate, and direct departmental projects with follow-through and appropriate follow-up.
15. Responsible for knowing and understanding project regulations and requirements, key deliverables, and compliance obligations.
16. Review and abstract appropriate clinical data and submit to the appropriate regulatory required database (i.e. IQR, OQR, NHSN, Cancer Registry, state database, etc).
17. Manage performance improvement projects, flow and alignment to assure milestones and key performance indicators are met within defined parameters. Document the results of projects, and submits other documentation as requested.

Infection Prevention

Investigates, controls, and takes measures to prevent infections within the facility including (but not limited to) a surveillance system to monitor, investigate, document, and analyze the occurrence of each potential infection control indicator, report findings and recommend corrective action to the appropriate multidisciplinary team.The incumbent is responsible for the facility's activities aimed at preventing healthcare-associated infections (HAIs) by ensuring that sources of infections are isolated to limit the spread of infectious organisms. Responsible for the development and administration of efficient and professional operations of occupational health services in accordance with OneCore health policies, practices, procedures, and applicable laws and regulations to achieve the desired goals and objectives.

• Collects, interprets and reviews infection control data from multiple sources and organizes data into spreadsheets.
• Collects, tracks, analyzes, and recommends actions for infection control including hand hygiene compliance, immediate use sterilization, SSIs, and Cleaning/Disinfectant compliance.
• Responsible for creating and distributing infection control education to train staff through education and dissemination of information in evidence-based infection control practices.
• Facilitates monitoring and investigating known or suspected infections to determine source and ensure control including tracking and analyzing outbreaks and implementing determined actions to resolve related problems.
• Responsible for the analysis and implementation of a formulated action plan to identify infection control discrepancies and risks.
• Conducts monthly assessment rounds to determine and identify infection control risks within the environment and report's findings to the appropriate committees. Develops and implements action plans related to findings.
• Maintains and updates infection control related logs including SSI reviews and employee exposures.
• Maintains current knowledge of key indicators from various regulatory agencies
• Oversees the compiling of information requested from physicians for infection control surveillance purposes.
• Knows and adheres to policies of the Hospital and demonstrates fiscal responsibility.
• Interprets, follows and applies Infection Control standards, policies, procedures, goals, and objectives according to accepted standards.
• Plans, implements, and evaluates the Infection Control Program of the Hospital, including reporting to and meeting with the multidisciplinary teams involved.
• Documents appropriately and fully. Secures missing data and other patient care needs.
• Maintains and demonstrates current skills and knowledge of applicable state and federal regulations and professional best practice standards.
• Teaches and encourages involvement of all staff in Infection Control programs. Also suggests changes in practice and/or environment to improve safety.
• Provides Infection Control post-operative surveillance, data collection, assessment, measurement, and reports findings to the appropriate committee.
• Provides surveillance and assessment of infection control practices related to Standard Precautions, Transmission Precautions and Exposure Control.
• Provides facility surveillance related to infection control.
• Provides review for the appropriateness of agents used for disinfecting and antisepsis.
• Reviews the Infection Control policies and guidelines for program scope, objectives, performance and effectiveness at least annually and provides recommendations to the appropriate committee for revision/approval.
• Oversees and manages the administrative and operational duties of employee health services.
• Provides or manages the required physical evaluation programs and services to meet regulatory requirements; such as OSHA, CDC, etc.
• Trains and leads ergonomic team to assess jobs and provide input regarding ergonomic improvements.
• Assists with the accident investigation program to identify root cause analysis of all incidents and near misses.
• Assists departments with identifying, evaluating and implementing accommodations and return to work options for workers with restricted duty.
• Maintains summaries and written reports required for employee illness/injury reporting.
• Trends employee illnesses/injuries to identify safety and health issues.
• Oversees workers' comp and return to work program
• Contributes in the design of controls for injury prevention and health surveillance related to actual and potential hazards in the work environment.
• Identifies primary, secondary, and tertiary prevention and health promotion strategies to optimize health of the population.

Licensure and Certification: Licensed as an RN in the state of Oklahoma. Basic Life Support certification is required within 30 days of hire.

Experience required: Bachelor's degree in nursing, healthcare administration, or a similar field of study with a strong analytical base required. Master's degree in nursing, healthcare administration, or a similar field of study with a strong analytical base is preferred. A minimum of three (3) years' experience in a hospital facility required; Quality/Risk leadership experience preferred. CPHQ (Certified Professional in Healthcare Quality) preferred.