Job Description

Hillcrest Hospital South is a full-service 180-bed hospital providing a wide range of inpatient and outpatient services using state-of-the-art technology in a friendly community setting. Consistent performance has helped the hospital be nationally recognized for patient safety.

POSITION SUMMARY 

The Quality Director ensures the delivery of quality patient care, promotion of safety and reduction of medical errors. This Director will gather quality and performance information and provide clinical analysis, designed to identify patterns of patient care events that may lead to sub-optimal outcomes and identify areas where patient care needs improvement. This position will also serve as the Facility Patient Safety Officer.

• Performs duties with little or no supervision competing assigned tasks within required time frames.
• Coordinates DNV, Department of Health State Licensing and other surveys for all clinical and non-clinical departments except for the business office.
• Notifies Ardent AVP of Regulatory Activities of any regulatory visits or correspondence within policy guidelines.
• Works with Ardent AVP of Regulatory Activities to develop plans of correction for any survey deficiencies.
• Assures QIO log is maintained.
• Accompanies external review agency personnel or surveyors on visits to hospital departments.
• Provides oversight for all regulatory requirements hospital-wide.
• Provides oversight of all credentialing functions.
• Maintains a current copy of State, Federal and DNV standards and regulations.
• Receives and distributes all Quality reports and refers problem areas to appropriate departments and committees for analysis and action.
• Provides oversight of Infection Control functions.
• Reviews and evaluates data from Infection Control, Core Measures, Quality Outcomes Profiles, CMS QIO data and relates the analysis of data to appropriate committees.
• Assists development and implementation of quality improvement teams as well as providing education as needed.
• Completes and maintains all applications and correspondence required by DNV. Maintains passworkds and identifiers for the organization.
• Provides oversight for risk management activities,
• Attends all Quality and Regulatory committees to ensure compliance with requirements.
• Attends all weekly administrative team meetings to present a report of all regulatory surveys and status of each clinical and non-clinical department’s state of survey quality improvement initiatives readiness for all regulatory agencies.

Education & Experience 

• BSN, MS preferred
• Oklahoma Nursing License

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