JOB SUMMARY:

The DQM assumes responsibility and accountability for the hospital-wide Continuous Quality and Performance Improvement program. The DQM will assist the CEO/leadership and Medical Staff to establish priorities for Performance Improvement. He/she ensures that disciplines in the hospital work collaboratively to plan and implement Performance Improvement activities. The DQM will focus on measuring, analyzing and trending information in order to improve outcomes. He/she will assure ongoing monitoring of performance to ensure that improvements are sustained. The DQM will direct and assist in compliance with federal and state regulations and accreditation standards.

ESSENTIAL FUNCTIONS:

Job Specific

• Provides leadership and oversight of a comprehensive, efficient and integrated organization wide Continuous Quality Performance Improvement program.
• Measures and assesses performance through collection, analyses, and trending of data.
• Focuses on processes and systems to improve performance.
• Directs, facilitates, and reports on all aspects of services relating to risk management and patient safety.
• Investigates factors contributing to adverse outcomes in order to improve processes and systems.
• Encourages reporting on risk reduction strategies in an atmosphere which minimizes blame or retaliation. Fosters environment to reduce unanticipated adverse events and/or outcomes.
• Responsible for education of Continuous Quality and Performance Improvement and additional hospital-wide education and training.
• Directs the functions and operation of the hospital-wide continuous quality improvement program including review of records for indicators of quality; reports findings to leadership, Medical Executive Committee, the Board of Managers and other committees as appropriate.
• Responsible for education of Continuous Quality and Performance Improvement to hospital and medical staff.
• Annually reviews hospital wide plans for the functions of IC and CQPI and establishes goals and objectives for the next year.
• Acts as a liaison to local health officials, coordinates inspections and accreditation reviews with state and other regulatory agencies.
• Demonstrates knowledge of growth, development, and the aging process for the planning and delivery of age-appropriate care.
• Other duties as assigned.

QUALIFICATIONS:

• Registered Nurse with current state licensure highly preferred.
• Clinical license required.
• Certification preferred by APIC (American Practitioners of Infection Control), and NAHCQ (National Association of Health Care Quality).
• BSN or BS/BA required. Two years of experience in an acute hospital or rehabilitation setting required. Previous supervisory experience preferred.
• Current Basic Life Support/CPR Card.
• Demonstrated ability to plan, coordinate, and evaluate PI activities, effective oral and written communication skills and proficiency in basic computer skills required.
• Working knowledge of staff development and the educational process, quality improvement, infection control/employee healthy, and safety/risk management standards.
• Effective oral and written communication skills, in English with additional languages preferred; proficiency in basic computer skills required.

Company Specific:

• Adheres to dress code, appearance is neat and clean and wears appropriate identification while on duty
• Completes annual health, safety, and education requirements. Maintains professional growth and development.
• Maintains confidentiality of all patient and/or employee information to assure patient and/or employee rights are protected.
• Reports to work on time as scheduled; adheres to policies regarding notification of absence.
• Attends all mandatory in-services and staff meetings.
• Represents the organization in a positive and professional manner.
• Complies with all organizational policies regarding ethical business practices.
• Communicates the mission, ethics, and goals of the hospital, as well as the focus statement of the department.
• Maintains current licensure/certification for position, if applicable.
• Consistently demonstrates customer service skills to patients, physicians, visitors, employees, and any other individuals with whom they may come in contact.
• Consistently follows departmental and hospital Health, Safety, Security, Hazardous Materials policies and procedures.
• HIPAA: Conduct job responsibilities in accordance with HIPAA privacy laws, follow hospital policy in provision of patient confidentiality. Able to identify patient confidentiality issues and reports to proper hospital personnel immediately.
• Compliance: Conducts job responsibilities in accordance with standards set forth in Kindred's Code of Conduct, Kindred policy and procedures, applicable federal and state laws, and applicable standards.

Language Skills:

• Able to communicate effectively in English, both verbally and in writing.
• Additional languages preferred.

Skills:

• Basic computer knowledge.
• Knowledge of basic equipment.
• Appropriate telephone communication skills.

Physical and Safety Requirements:

• Good general health and stress coping ability. Full mobility and ability to participate in vigorous activity. Ability to clearly and effectively communicate with all constituents (patients, families, peers, and other healthcare team members) as needed for assessment, intervention, and professional development. Possess near vision acuity for accurate reading of equipment and recording on patient charts. Must be physically able to lift, support and move patients.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising patient care.

Job : Compliance/Quality/Risk Primary Location : IL-Edwardsville-Anderson Rehab Hospital Organization : 4098 - Anderson Rehab Hospital Shift : Day