Director of Quality and Infection Prevention

Within the framework and the objectives and policies established by the Chief Executive Officer, monitors and coordinates NMMC quality improvement programs and activities to insure they are ongoing in an effective and efficient manner.  Evaluates the quality and appropriateness of patient care, pursues opportunities to improve care, improve patient safety and resolve identified problems.  Coordinates continuous compliance with Joint Commission, state and federal licensure regulations and coordinates surveys.  Maintains functions necessary to excel in the public reporting of quality data and in pay-for-performance initiatives.

ESSENTIAL FUNCTIONS:

• Maintains the organization in a state of continuous compliance and ever-readiness.
• Coordinates any survey-related process through the follow-up activities required for identified opportunities for improvement.
• Maintains thorough industry knowledge on quality and performance excellence and innovation.
• Utilizes best practices, tools, and data to communicate performance improvement opportunities to directors, supervisors, physicians, advanced practice personnel, and other leaders to promote clinical and operational effectiveness. Complies with all Joint Commission, CMS, and State requirements regarding QI.
• Facilitates the development and implementation of action plans while working with Quality Improvement Teams.
• Receives and reviews results of QI activities conducted within the organization.
• Identifies trends/patterns and promotes performance improvement projects.
• Oversees patient safety and reviews incidents as deemed appropriate.
• Maintain functions necessary to excel in the public reporting of quality data.
• Responsible to oversee the infection prevention program at NMMC.
• Maintains, evaluates, and revises infection prevention strategies organization wide.
• Participates in Joint Commission and CMS public reporting requirements.
• Maintains competency with training/professional development in infection control, including CIC certification. Coordinates infection prevention training and competencies for all staff.
• Manages employee health charts and needs, including but not limited to immunizations and requirements for safe employment.
• Maintains educational training/professional development.
• Maintains professional demeanor and confidentiality of medical information.
• Orients of new Medical Staff and Nursing staff to Quality Improvement as well as Licensing and Accreditation.
• Responsible for patient and employee safety as it applies to the work environment.
• Perform such related duties not listed herein but deemed in the best interest of Northern Maine Medical Center.
• Excellent planning skills.
• Organizes people and resources for efficiency, fiduciary responsibility, and success.
• Effectively handles employee conflicts.
• Helps others take responsibility and action.