PRINCIPLE JOB FUNCTIONS
· Oversees the hospital wide performance improvement including patient safety initiatives by facilitating the Plan Do Check Act (PDCA)process
Responsible for regulatory compliance: maintaining standards and instituting new measures
· Collaborates with other health care providers in assessing, planning, implementing, and evaluating performance improvement programs and clinical outcomes.
· Participates in peer review and other means of evaluation to assure quality of patient care delivery including the PI process
· Responsible for coordinating ORYX indicators: submitting information, analyzing and sharing results to appropriate management staff.
· Manifests problem solving abilities and decisive leadership, utilizing innovative thinking and approaches
· Responsible for physician PI and peer review
· Networks with peers and colleagues both within the organization and in the community
· Responsible for overseeing the privilege and credentialing process for physicians and allied health members
· Oversees and participates in Medical Executive Committees, including minutes and record keeping
· Adheres to hospital policies and procedures.
· Conduct reinforces the Company’s values and promote the Code of Conduct
· Meets his or her leadership obligations under the Ethics and Compliance Program
· Performs other duties as requested or required.
* Graduate of an accredited school of Professional Nursing. *Current licensure as a Registered Nurse with the Board of Nurse Examiners for the State of Texas.
* BSN required, MSN preferred.
*Four years of progressively responsible experience in quality improvement related areas. Prefer experience with The Joint Commission (TJC) surveys, TDH and CMS.
HCA Inc - 15 months ago