Job Description

Responsible for direction of the Quality Management Department and the various functions under its umbrella, including Quality Improvement and Infection Prevention. Provides reports to the QM Committee, Medical Executive Committee, Board of Directors, administrative team and health plans as requested and required. Maintains quality improvement activities within the department and participates in CQI activities. Assures collaboration between quality, risk and utilization management functions. Assists in formulating and monitoring the budget for the areas included.

Responsible for developing and implementing policies and procedures for quality and risk management. Reviews and approves policies and procedures. Responsible to facilitate preparation for review by all regulatory agencies. Educates and assists department managers to maintain appropriate policies, procedures, and documentation to fulfill requirements and regulations. Demonstrates current clinical knowledge as well as current knowledge of regulations and standards as relating to AOA, JCAHO, HCFA, State Health Departments and regulatory agencies. Our hospitals are DNV! Remains current in the appropriate fields encompassed by the departments.

Develops QM plan. Prepares quarterly and annual evaluation of QM program and plan, presents this to QM Committee and Board of Directors. Develops QM annual work plan, monitors work plan to evaluate time frame compliance. Provides education to staff on risk management, and performance improvement. Ability to plan and organize orientation and inservice training for department staff members, participates in guidance and educational programs.

Position is responsible for Quality at both St. Luke's Medical Center and Tempe St. Luke's Hospitals. Multi-campus Quality Director experience required or managing quality for approximately 275 + acute care hospital beds required. Experience with Accreditation onsite inspections; corrective action plans; both drafting and implementing required.

- Current Arizona Registered Nurse Licensure.

- BSN required.

- Master's Degree in Health Services Administration Preferred.

- 3 or more years of previous clinical experience in an acute care setting.

- 2 or more years of Quality Management Director experience in an acute care hospital setting. CPHQ Certification or able to obtain within one year.

St. Luke's Medical Center / Tempe St. Luke's Hospital are Equal Opportunity Employers.

Application Instructions

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