Quality Officer

Job Description

• Assists in planning, implementing, and monitoring of the Quality Improvement and Patient Safety Program.
• Assists in developing data collection tools for key performance measures and other identified trends.
• Assists in reviewing information technology infrastructure required to support a hospital-wide performance, quality improvement and reporting system.
• Assists the various department leaders in ensuring full compliance with the requirement of data collection, analysis, reporting and action.
• Develops, in coordination with IT, a data display technique and reporting format which can be used hospital-wide for all data management.
• Ensures needed data is collected on a timely basis; regular progress reports are distributed and make recommendations for future improvement in the infrastructure and systems.
• Assists in monitoring activities and core measures, inclusive of the measures required from the Joint Commission International (JCI) Library of Measures.
• Assists in developing and monitoring hospital policies, plans and programs.
• Guides and monitors the development of clinical practice guidelines, protocols, pathways, and order sets.
• Develops, implements, and coordinates education programs relating to data analysis and performance improvement.
• Analyzes all assigned areas for opportunities for improvement and makes applicable recommendations for process, system, procedure, and operational changes to improve healthcare value and quality (ie: Core Measures, Hospital Acquired Conditions, etc).
• Assists in the management of performance improvement projects, flow and alignment to ensure milestones and key performance indicators are met within defined parameters.
• Documents the results of projects, and submits other documentation as requested.
• Coordinates with the assigned Quality staff data validation on required data elements.
• Represents the Quality Department in Quality Improvement (QI) and other hospital-identified Committees during the absence of the Quality Manager.
• Acts as an internal consultant in the areas of regulatory, process improvement, performance monitoring, and statistical analysis and makes recommendations to the committee based on best practices and current regulatory standards.