Directory, Quality, Accreditation and Infection Prevention

Phoebe Putney Memorial Hospital, Inc.; United States; On-site; USD 90,000 - 130,000; Full time

Job summary

The Phoebe Putney Memorial Hospital, Inc. seeks aQuality Improvement leader to coordinate QAPI initiatives, oversee infection control surveillance, and ensure mandatory CMS/state reporting and accreditation readiness.

The role requires strong project management skills, a background in healthcare quality, and experience leading cross-functional teams to drive data-driven improvement and regulatory compliance across the hospital system.

Qualifications

• Bachelor's degree in a relevant field is required.
• Master's degree in a relevant field is preferred.
• Minimum 3 years of Quality Improvement and Project Management experience required.

Responsibilities

• Lead implementation of the annual QAPI plan and allocate resources.
• Oversee infection control surveillance and identify infections/outbreaks.
• Coordinate CMS/state reporting of quality indicators and regulatory compliance.
• Lead or participate in quality improvement teams and audits.
• Maintain relationships with regulatory agencies and accrediting bodies.

Skills

Quality Improvement

Project Management

Education

Bachelor's Degree in a relevant field

Master's Degree in a relevant field

Job description

Job Description Summary

This position is responsible for facilitating the Quality Improvement Program, overseeing Infection Control Surveillance Program, Mandatory reporting of quality indicators to CMS and State, Coordination of medical staff peer review and quality reports, coordination of compliance with accreditation agency and clinical regulatory standards.

This position is responsible for facilitating the hospital Quality Improvement Program, overseeing Infection Control Surveillance Program, Mandatory reporting of quality indicators to CMS and State, Coordination of medical staff peer review and quality reports, coordination of compliance with accreditation agency and clinical regulatory standards.

Qualifications

• Bachelor's Degree in relevant field (Required)
• Master's Degree in relevant field (Preferred)

Work Experience

• 3 or more years Quality Improvement, Project Management experience (Required)

Licenses and Certifications

• CPHQ - Certified Professional in Healthcare Quality (Preferred)

Essential Functions

Lead implementation of the annual Quality Assessment and Performance Improvement (QAPI) plan ensuring the allocation of resources to achieve success. Develop comprehensive, strategic and tactical plans to achieve hospital level progress in goal achievement; revises strategic plans accordingly. Utilize and foster use of evidence-based medicine to reduce unnecessary variation to standardize care and reduce costs. Inspire and guide team members through change while maximizing efficiency and effectiveness. Foster a culture of flexibility, innovation, and continuous learning. Develop, participate in, and/or lead quality improvement teams/committees; drives the implementation of evidenced based prevention strategies and monitors process and outcome measures toward success. Collaborate with others across Phoebe Health System to inspire a system approach where appropriate Stay current on industry trends and best practices to ensure the organization remains at the forefront of quality and safety initiatives. Partner with system and hospital leadership to ensure compliance with Federal and state standards and achieves a continual state of readiness. Stay abreast of all pertinent federal, state and hospital regulations, laws, and policies Manages regulatory compliance activities including preparation for survey, survey and follow-up documentation, corrective action planning/completion etc. Develops and maintains relationships with regulatory agencies and accrediting bodies Partner with system and hospital leadership to lead a highly reliable organization and to achieve a goal of zero harm Engage in and foster a culture of trust and transparency with the aim to reduce errors using just culture principles Conduct and/or lead others in root cause analysis, common cause analysis, failure mode effects analysis (FMEA), proactive risk analysis Ensure compliance with organization’s incident reporting system in a timely and accurate manner. Develop comprehensive, strategic and tactical plans to achieve hospital level progress in infection prevention goal achievement; revises strategic plans accordingly. Supervise and coordinate hospital infection control surveillance to identify actual nosocomial infections, clustering and outbreaks of infection and infection potentials. Plan and provide education and guidance in infection control and prevention measures. Ensure compliance with regulatory, accreditation and licensure requirements pertaining to infection control. Stay current on industry trends and best practices to ensure the organization remains at the forefront of infection prevention and control initiatives. Establish and monitor key performance indicators across the organization. Oversees the collection, analysis, assimilation, and reporting of quality data to drive improvement. Provide scheduled reports and data to leadership, committees, and external agencies Partner in advancing analytical and technological solutions to improve data integrity and accuracy; standardizes quality reporting across the system where applicable.

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Employer Culture

Phoebe Putney Health System is southwest Georgia’s preferred career choice for professionals who want to improve the community’s health by joining a respected, cutting-edge team. We offer you the opportunity to collaborate with the best colleagues in a friendly, close-knit setting that feels like family. Your career at Phoebe will allow you to apply learned skills, explore new paths and advance into greater opportunities. There's more for you at Phoebe. Phoebe is simply the best, most advanced healthcare provider in the region. If you want to work in the medical field, we are the preferred choice, with the best technology, the most specialists and the area’s top talent. If you are searching for a non‑clinical career that allows you to serve the community and grow, you’ll also find us ideal. We’re one of the area’s premier employers, offering a close‑knit culture, outstanding benefits and many ways to develop your career.