BASIC PURPOSE OF THE JOB Develops, coordinates, implements, maintains and supervises the quality management department and infection control programs.REPORTS TO Vice President-Patient Care ServicesJOB REQUIREMENTSSupervisory Responsibilities: YesMinimum Education: Bachelors required; Masters preferredDegree: Degree in Nursing, Health Information Management or related clinical fieldLicense/Certification Required: Registered Health Information Administrator (RHIA) or Certified Professional in Healthcare Quality (CPHQ); TN or Compact RN Licensure Required.Minimum Work Experience: 5 years in quality management or an acute care setting, pediatrics preferred. Infection control experience and certification preferable.REQUIRED KNOWLEDGE, SKILLS, AND ABILITIESStrong verbal and written communication skills.Excellent leadership, organization and time management skills.Strong computer skills including proficiency in MS Office.Strong analytical skills.DUTIES AND RESPONSIBILITIESDemonstrates ongoing collaboration with medical staff leadership, other clinical and administrative leadership regarding the development and implementation of priorities to improve clinical outcomes, reduce preventable patient harm, and alignment with strategic initiatives.Provides oversight to the provision and support of current best practice methods to improve patient safety and clinical outcomes which emphasizes human factors in a just culture.Serves as internal consultant and educator to hospital and medical staff on performance measurement for compliance with external requirements such as The Joint Commission, Vermont Oxford Neonatal Network, nursing Magnet clinical measures, etc.Oversees ongoing review for compliance, effective processes, and improved relevancy for ongoing professional performance evaluation (OPPE) and peer review as required by clinical leadership.Serves as facilitator, coordinator, and/or educator as needed in the root cause analysis process and the pro-active risk analysis process.Oversees the accuracy and timeliness of multiple measures and databases utilized in quality management and infection control activities.Serves as ETCH quality/patient safety liaison in external pediatric groups such as Children's Hospital Association (CHA) Forums and the Solutions for Patient Safety (OCHSPS) Eliminating Serious Harm project.Serves as the designated CBISA reporter for the department. Reports benefit activities, communicates benefit stories, calculates event detail and enters information into Lyon Software (CBISA) program.Completes reports monthly with an understanding that all fiscal year entries be completed no later than August 1 of the next fiscal year.Maintains an effective surveillance system by monitoring daily patient admissions, lab reports, patient discharge medical records, and multi-departmental patient care reports.#J-18808-Ljbffr