Manager of Hospital Clinical Quality
‘‘‘1.1 Ensures overall compliance with nationally reported quality data.
‘‘‘1.2 Develops strategies and initiatives to ensure clinical quality indicators compliance.
‘‘‘1.3 Communicates and collaborates with other departments in addressing clinical quality outcomes.
‘‘‘1.4 Performs activities of interviewing, hiring, disciplining and termination.
‘‘‘1.5 Develops, justifies and maintains departmental budgets; monitors supply costs.
‘‘‘1.6 Works in collaboration with Physician Advisor to ensure appropriateness of patient care.
‘‘‘1.7 Ability to identify staff learning needs, assist in planning and organizing orientation and inservice training for employees. Ensures attendance of employee at mandatory education.
‘‘‘1.8 Conducts annual performance reviews of employees in a timely manner and ensures completion of mandatories.
‘‘‘1.9 Develops first line leadership.
‘‘‘1.11 Ensures compliance to state, federal, and JCAHO regulations.
‘‘‘1.13 Evaluates and updates policies and procedures. Ensure compliance of employees.
‘‘‘1.14 Maintains an open line communication with employees, physicians and administration. Conducts regular staff meetings and develop mechanisms to enhance communication.
2.1 Proactively conducts department rounds and reports findings related to Environment of Care to Safety Officer or other responsible personnel, then follows-up to assure timely and satisfactory resolution/closure.
2.2 Participates with PGH Environment of Care Team during their scheduled rounds, reviews findings, then follows-up to assure timely and satisfactory closure.
2.3 Complies with PGH infection control initiatives including departmental hand-washing monitoring/compliance.
2.4 Provides department-specific training for new employees and once annually for current employees that addresses specific employee expectations and responsibilities regarding fire drills/safety, disaster response, unit security, clinical equipment use, and hazardous waste disposal.
4.1 Communicates and collaborates with other departments in addressing patient care issues and in formulating performance improvement activities.
4.2 Participates in performance improvement teams as assigned; develops and implements strategies to ensure PI compliance.
4.3 Attends and actively participates in medical staff and hospital committees and meetings, as assigned.
4.4 Participates in hospital wide patient experience initiatives i.e. HCAHPS compliance and patient experience committee.
‘‘‘4.5 Monitors and assures core measure/quality indicators compliance on unit and/or department.
‘‘‘4.6 Participates in hospital wide Performance Improvement Council meeting; attends monthly meeting, develops and monitors unit and/or department specific indicators as identified, submit data as assigned/timely.
4.7 Assures state of regulatory readiness at all times on assigned unit and/or department.
4.8 Assures timely review and turnaround of concurrent data and drill down.
5. Compliance Standards
5.1 Achieves Compliance with State, Federal, Joint Commission regulations and standards.
‘‘‘5.2 Follows all hospital and Tenet Healthcare policies and procedures.
5.3 Exhibits high ethical standards and integrity.
‘‘‘5.4 Reports all potential compliance issues as per Regulatory Compliance Policy COMP-RCC 4.21 Internal Reporting of Potential Compliance Issues.
‘‘‘5.5 Ensures that staff completes Ethics and Compliance Initial and Annual Training timely.
6. Infection Control Standards
6.1 Monitors hand hygiene practices and submits findings to PI Council and Infection Prevention and Control practitioner.
6.2 Responds to Infection Prevention and Control request for follow up within the requested time frame.
6.3 Submits daily, accurate invasive device log.
6.4 Rounds on patient's room and monitors compliance with IV therapy: IV sites dressing dated, timed and intact; IV tubing appropriately labeled; report/follow up on items in need of repair.
- Graduate from an approved nursing educational program as defined by the National Council of State Boards '''of Nursing (NCSBN)
- Bachelor’s degree or Ma, in Nursing or related field preferred
- Minimum two (2) years management experience preferred
- Minimum five (5) years of nursing experience preferred
- Demonstrates leadership, critical thinking and time management skills
- Quality Assurance/Utilization Management Certification preferred
- Current Florida RN License
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Job Status: Full Time
Job Reference #: 120831