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Rutherford Regional Health System is a 143-bed acute care facility that offers a broad array of inpatient and outpatient care. Rutherford Regional is dedicated to providing patients with a full range of services to meet their healthcare needs. We provide our services in a caring, professional environment through the teamwork of our medical staff and employees.

Rutherford Regional Health System’s partnership with Duke LifePoint Healthcare is bringing the pieces together to transform healthcare in Rutherford County. Duke LifePoint Healthcare is a joint venture of Duke University Health System, one of the country’s leading academic health systems, and LifePoint Health, a leading healthcare company dedicated to Making Communities Healthier. These two forces joined because of the shared interest in collaborating with hospitals, healthcare providers and patients to bring high quality, innovative healthcare services to communities. Duke LifePoint combines Duke’s unparalleled expertise in clinical excellence and quality care with LifePoint's extensive resources and knowledge and experience operating community hospitals and healthcare organizations.

The Director of Quality is responsible for ensuring that the facility remains in compliance with Joint Commission, state and federal standards; oversight responsibility for all regulatory body surveys, i.e., Joint Commission, State licensing Reviews, CMS Validation Surveys, health department, local regulatory reviews (fire marshal), and any other regulatory activity that may involve the facility. This responsibility includes staying current with Joint Commission, state, and local standards; educating facility staff about standards; and preparing the facility for such accreditation surveys.

Plans and coordinates quality and regulatory compliance activities to assure appropriate, high quality and regulatory compliant healthcare delivery. This includes development and implementation of hospital-wide Quality Assessment/Performance Improvement plans. Evaluation of effectiveness of corrective actions for identified problems and continuous quality improvement activities. Coordinates assessment of clinical practice patterns for purposes of medical staff credentialing and reappointment. Supervises staff responsible for coordinating a hospital-wide program aimed at compliance with Joint Commission core measure and Medicare quality initiatives.

Essential Functions:

• Works with all hospital services to hardwire reliable delivery of healthcare systems that incorporate best practice healthcare quality methodologies.
• Initiates and oversees the development of a comprehensive hospital quality and regulatory compliance improvement program inclusive of the analysis and trending of data related to hospital initiatives to improve the healthcare services provided to patients.
• In collaboration with the Director of Risk Management, facilitates Sentinel Event Investigations and development of root cause analysis and corrective actions within 10 days of sentinel event identification. Reports findings to the CNO. Facilitates development of corrective action planning and monitoring of compliance with endorsement of medical staff leaders and/or hospital administration.
• Coordinates review of quality indicators from appropriate medical staff departments. Trends variances and facilitates medical staff chart reviews when appropriate. All work must be completed in time to include in appropriate quarterly report (OPPE/FPPE).
• Coordinates Medical Staff Peer Review Committee.
• Provides leadership and/or participates in committees and communicates vertically and horizontally within the organization.
• Provides direction to ensure that clinical services are provided in accordance with regulatory standards established by federal and state agencies and The Joint Commission accreditation standards, including The National Patient Safety Goals.
• Develops score card and/or dashboard indicators in conjunction with the medical and nursing staff and the hospital leadership as a mechanism for tracking adherence to agreed upon quality and regulatory goals.
• Completes regulatory rounding observation in each hospital department at least quarterly and in conjunction with department and hospital leadership, develops solutions to issues identified during rounding.
• Keeps the CNO informed of quality and regulatory priorities, initiatives, and incidents.
• Develops and fosters collaborative relationships with all employees and medical staff in implementing best practices in patient and hospital quality.
• Collaborates with the Duke/LifePoint quality representative(s).
• Proactively communicates with and educates managers/directors, medical staff, and hospital staff regarding quality and regulatory initiatives and activities.
• Remains fully informed regarding national, state, and local quality and regulatory mandates.
• Coordinates and/or presents quality information for meetings.
• Prepares for and acts as lead for licensing and other regulatory surveys as well as any required follow up action plans and monitoring. This includes oversight of information entered into The Joint Commission webs site.
• Revises and updates the Quality Management plan annually.
• Participates in Administrator on Call Program.
• Performs other duties as assigned.
• Employee supervises others.
• Collaborates with administrators, medical staff leadership, committees, and directors to identify potential loss exposures, plan risk management initiatives, monitor effectiveness of the risk management program and integrate risk management into the operational level of the organization to reduce or prevent loss.

Minimum EducationBachelor's Degree requiredMaster's Degree highly preferred

Required SkillsRequires critical thinking skills, decisive judgement and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action. Must have excellent skills in conflict resolution strategies. Proficiency with Microsoft Office Suite, including Excel. Certifications:Basic Life SupportCertification as a Professional in Healthcare Quality (CPHQ) through National Association for Healthcare Quality (NAHQ) or completion within two (2) years of hire. Must maintain certification throughout employment.Certification: Professional Patient Safety (CPPS) or completion within two (2) years of hire.Must maintain certification throughout employment. Licenses:Current, unrestricted RN license to practice in NC (NC licensure or multi-state [compact] license).

Minimum Work ExperienceThree years of leadership experience in acute hospital setting required. Two years’ experience leading quality/performance improvement and Joint Commission/CMS survey preparation and coordination preferred. Knowledge of medical staff oversight/credentialing preferred.

Benefits - Wide range of benefits options!

Here at Rutherford Regional, you choose your own Medical, Dental, and Vision plans from a variety of competitive options that give you the coverage that best fits your needs.

• HSA

• 401(K) retirement plan contributions

• Generous Paid Time Off

• Accident & Critical Illness Insurance

• Prescription Assistance with OptumRx

• Income protection programs for the entire family such as life insurance, Short/Long-term Disability, and Identity Theft.

• Employee Assistance program at no cost to you to provide emotional, legal, financial, and daily life support for your entire household. Services are available 24 hrs. a day, 7 days a week.

• Free travel and entertainment discount program to ensure you enjoy your time away from work.

Why join our team?

We are dedicated to providing patients with a full range of services to meet their healthcare needs, and we believe our employees are our most valuable assets in accomplishing this goal. Rutherford Regional is growing its team of dedicated health care professionals. If you are looking to start a /career that cares/, are passionate about changing lives, and ready to work in a supportive environment in a close-knit community, apply today!

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Title: Director of Quality

Location: NC-Rutherfordton

Requisition ID: 7462-9348