The Director of PI/Quality Management reports directly to the CNO but works closely with all Hospital Senior Leaders and Department Management Staff as well as the Medical Staff Leadership. The Director of PI/Quality Management is also the liaison between the facility and the Corporate Quality Management for Joint Commission compliance and other issues related to Quality of Patient Care issues involving other regulatory compliance agencies. The Director of PI/Quality Management supports maximizing the delivery of quality care throughout the organization, supports system processes and outcomes to ensure safe, quality patient care, compliance with all standards and regulations, and supports the organization's mission, vision, strategic and business planning initiatives.
ESSENTIAL JOB FUNCTIONS:
1. Has oversight of an effective Quality Improvement Program.
2. Is responsible for the organization's Joint Commission Survey and Readiness program.
3. Has oversight of the Joint Commision Oryx (Core Measure) requirements and expectations as directed by the UHS Corporate Quality Management Department..
4. Assists with meeting other regulatory agency quality of care requirements such as those delineated by Centers for Medicare and Medicaid (CMS) under the conditions of Participation (CoP) regulations, and the Texas Department of Health and Human Services (TDHHS), etc.
5. Oversees the department's budget and personnel functions and expectations.
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