Summary:
The Quality Director has knowledge of JCAHO standards, federal and state regulations.
Responsibilities:
Reviews and Revises hospital wide policies and procedures to follow the standards set forth by CMS and JCAHO.
Coordinates the Board’s, Medical Staff’s, and hospital staff’s roles in JCAHO compliance and survey preparation.
Provides data and analysis reports to the various organizations; local, division, state and group leaders on an ongoing basis, as appropriate.Maintains Physicians’ awareness of their Quality Management performance on an on-going basis through individual and committee reporting. Provides Performance Improvement leadership and consultative services for hospital and medical staff in effectively achieving regulatory accreditation and organizational compliance for Performance Improvement. Reports Performance Improvement Data for both the hospital and the medical staff dep...