Hospital Quality & Compliance Director
2.
5 Secaucus, NJ Secaucus, NJ Full-time Full-time Estimated:
$97.
4K - $123K a year Estimated:
$97.
4K - $123K a year Responsible for developing and overseeing the implementation of the Performance Improvement Plan in accordance with DOH, CMS, and DNV requirements.
Remains current with regulatory requirements related to implementation of a Performance Improvement program and on-going PI process.
(Includes but is not limited to CORE measures, restraint use, blood use.
) Submits data, reports to regulatory agencies within required timeframe, ie CORE measures, staffing, DNV.
Actively participates with performance improvement program through data collection, chart review, analysis of data, and initiating plan of correction for non-compliant areas.
Coordinates Patient Safety and Quality Committee meetings, prepares agenda and completes meeting minutes.
Monitors for compliance with safety regulations for the hospital to ensure the safety of staff, patients, and visitors.
Coordinates monitoring of restraint use according to regulatory requirements.
Provides education on PI plan and hospital based initiatives to new hires and staff on an on-going basis.
Provides medical staff office physician specific data for on-going physician performance evaluation.
Reviews incident reports to identify reportable events to DOH, track and trend incidents and identify opportunities for performance improvement.
Coordinates Root Cause Analysis teams as required.
Reports through the state electronic reporting system any reportable events.
Assists managers in the preparation for regulatory and accreditation surveys and monitors for continued compliance.
Assists managers in completion of corrective action plans for any citations and/or areas of non-compliance.
Participates in committees as assigned (Infection Control, EOC P&T) Prepares quarterly report of PI activities and performance for the Governing Board.
Has the responsibilities and authority, in conjunction with senior leadership, for ensuring that the requirements of the QMS are determined , implemented and maintained Coordinates monthly mortality reviews with CMO.
.
Estimated Salary: $20 to $28 per hour based on qualifications.
5 Secaucus, NJ Secaucus, NJ Full-time Full-time Estimated:
$97.
4K - $123K a year Estimated:
$97.
4K - $123K a year Responsible for developing and overseeing the implementation of the Performance Improvement Plan in accordance with DOH, CMS, and DNV requirements.
Remains current with regulatory requirements related to implementation of a Performance Improvement program and on-going PI process.
(Includes but is not limited to CORE measures, restraint use, blood use.
) Submits data, reports to regulatory agencies within required timeframe, ie CORE measures, staffing, DNV.
Actively participates with performance improvement program through data collection, chart review, analysis of data, and initiating plan of correction for non-compliant areas.
Coordinates Patient Safety and Quality Committee meetings, prepares agenda and completes meeting minutes.
Monitors for compliance with safety regulations for the hospital to ensure the safety of staff, patients, and visitors.
Coordinates monitoring of restraint use according to regulatory requirements.
Provides education on PI plan and hospital based initiatives to new hires and staff on an on-going basis.
Provides medical staff office physician specific data for on-going physician performance evaluation.
Reviews incident reports to identify reportable events to DOH, track and trend incidents and identify opportunities for performance improvement.
Coordinates Root Cause Analysis teams as required.
Reports through the state electronic reporting system any reportable events.
Assists managers in the preparation for regulatory and accreditation surveys and monitors for continued compliance.
Assists managers in completion of corrective action plans for any citations and/or areas of non-compliance.
Participates in committees as assigned (Infection Control, EOC P&T) Prepares quarterly report of PI activities and performance for the Governing Board.
Has the responsibilities and authority, in conjunction with senior leadership, for ensuring that the requirements of the QMS are determined , implemented and maintained Coordinates monthly mortality reviews with CMO.
.
Estimated Salary: $20 to $28 per hour based on qualifications.
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