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Job Description - Quality Director

The Quality Director is responsible for planning, implementing, and overseeing the Quality Program to ensure it aligns with the hospital's needs and meets the standards approved by the Hospital Governance Committee, under the guidance of the Corporate Quality Director. This role provides education and training to leadership, medical staff, hospital staff, and the Governing Body. The Quality Director facilitates performance improvement and Continuous Quality Improvement (CQI) activities across the hospital, as outlined in the QAPI plan. The position also serves as a resource to the administrative team, department managers, and medical staff, assisting in preparation for committee meetings as needed. The Quality Director plays a key role in preparing for regulatory body surveys, such as accrediting organization reviews, State Licensing Reviews, and CMS Validation surveys. The role is focused on three core categories: Quality Management, Risk Management, and Staff Education.

Key Responsibilities:

Quality Management:

• Implement and manage the Quality Assessment Performance Improvement (QAPI) plan to address the hospital’s needs.
• Educate medical staff, hospital staff, and the Governing Body on quality standards.
• Facilitate performance improvement and CQI activities across the hospital.
• Act as a resource to the administrative team, department managers, and medical staff.
• Assist department managers in preparing for medical staff committees.
• Ensure compliance with regulatory body surveys, including accrediting organizations, State Licensing Reviews, and CMS Validation surveys.
• Oversee performance improvement activities throughout the hospital.
• Drive the management of the Risk Management and Utilization Plan as part of the QAPI framework.

Risk Management:

• Identify and evaluate clinical risks and coordinate corrective actions to address risk issues.
• Educate staff on risk management practices to promote safe work practices and quality care.
• Collaborate with hospital departments, administration, and legal counsel on risk management programs.
• Report potential and real risks to the Governing Body, medical staff, administration, and relevant committees.
• Develop and monitor strategies to minimize risks associated with patient care and hospital services.

Clinical Staff Education Director:

• Oversee and direct the clinical education programs for the hospital staff.
• Manage educational activities to meet the needs of both patients and staff.
• Consult with department directors, staff, physicians, and nursing personnel to assess and address educational needs.
• Assist in developing and recommending educational policies and procedures.
• Serve as a resource to both staff and management regarding educational initiatives.

PREFERRED KNOWLEDGE, SKILLS, AND EXPERIENCE:

Education:

• Current clinical licensure in the State of Practice.

Experience:

• A minimum of two (2) years of experience in a clinical setting within healthcare or the medical industry.
• Previous experience in quality management or performance improvement activities is preferred. If experience is below the required standard, candidates must be enrolled in ongoing coursework in performance improvement and CQI methodology.
• Familiarity with mobile tools and applications.
• Demonstrated ability to exceed minimum standards and continually improve.
• Proficiency in using PCs, tablets, and smartphones.

Additional Skills:

• Strong verbal communication skills.
• Excellent organizational and interpersonal skills.
• Adaptability to changing schedules and environments.
• Strong analytical and problem-solving abilities.
• Ability to read, comprehend, and follow written and verbal instructions.

CERTIFICATES, LICENSES, AND REGISTRATIONS REQUIRED:

• Photo ID
• Social Security Card
• Clinical Licenses

Freedom Behavioral Hospital of Bastrop provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity, or any other characteristic protected by federal, state, or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.