GENERAL SUMMARY: # The Chief Quality Officer (CQO) reports to the President /CEO and is responsible for the leadership of the following departments and functions: # ### Regulatory Compliance and Continual Survey Readiness
####Assesses and implements structures and systems to enhance efficiencies and outcomes in these areas
. Assesses staff developmental needs for reporting departments#and assures resources and educational opportunities to enhance staff knowledge to#facilitate their effectiveness. Supports the Mission and Vision of RML Specialty Hospital by demonstrating RML#s Values of Service, Teamwork, Accountability, Integrity, Respect and Stewardship (STAIRS) in all actions.# Promotes a positive customer experience by exemplifying the principles of the Language of Caring in all interactions with patients, families and co-workers.
Supports RML#s efforts to be a High Reliability Organization (HRO). Develops and manages the budget for the assigned departments.# Completes monthly variances as required. Interviews, hires, develops, evaluates, disciplines and discharges (when necessary) subordinate personnel. Participates as a member of the hospital#s Administrative Council.
Facilitates the Quality and Patient Safety Committee and serves on other committees as assigned.# Infection Prevention Ensures the full implementation and annual review of the hospital#s Infection Prevention Plan. Ensures that infection data is reported to the PNT-IP Committee as required.# Performance Improvement# Facilitates the selection of quality and performance indicators and provides oversight of the process of data collection, analysis and reporting and the integration of results into performance improvement activities.# Insures data is used to analyze processes and improve patient care. Develops a performance improvement plan related to issues identified through event reports, regulatory surveys, patient satisfaction outcomes or other sources of data pertinent to our patient population.
Regulatory Compliance and Survey Readiness# Develops and implements a continuous survey readiness program to ensure successful regulatory surveys. Assesses hospital staff knowledge of and compliance with all applicable state and regulatory quality and reporting standards.# Develops and implements educational programs to address deficiencies or to implement processes to meet new standards. Directly manages surveys (mock, announced or unannounced).# Works with hospital leadership to develop a plan of correction related to survey outcomes.# Insures timely submission of plans of correction and follow up reports.# # #JOB REQUIREMENTS # CHARACTERISTICS # # MINIMUM PREFERRED Skills # Abilities Comprehensive understanding of quality control, physician peer review, performance improvement, and strategies for the inpatient hospital environment # Working and applied knowledge of a performance improvement methodoloygy, such as Lean and Six Sigma # # Leadership ability to foster collaboration and team building across departments, with the medical staff, and with patients and families.# # Demonstrated skill in critical thinking, diplomacy. # Excellent communication skills to interact positively with #persons throughout the organization including clinicians. # Organizational skills to prioritize work, meet frequent deadlines, and manage others effectively. # Knowledge and understanding of the LTACH prospective payment systems. # In-depth knowledge of external clinical quality reporting requirements. # # Knowledge # Experience Bachelor#s degree in a clinical discipline required. # Masters degree in healthcare or related field strongly preferred. # Five or more years experience as a leader for performance excellence and quality. # Three#or more years management experience # # Progressive leadership experience, including multiple department management.
License # Certifications # Certification in quality management. Working Conditions Work is performed in an office and patient care environment. The above statements are intended to describe the general nature and level of the work being performed by people assigned to this job.# They are not exhaustive lists of all duties, responsibilities, knowledge, skills, abilities, and working conditions associated with it. 03.2017
RML Specialty Hospital