Salary Range: $72.57 - $97.59 Pay rates are determined based on experience and internal equity. Position Summary: + Reports directly to the Chief Nursing Officer. + Has responsibility for services at all LVMC Facilities (Acute Hospital, Comprehensive Care Center and The Champion Center). + The Director of Quality Improvement, Risk Management & Infection Control (Director of QI/RM/IC) must have a broad knowledge of care of patients in the hospital setting. + Plans, coordinates, and implements effective quality performance and quality improvement systems with the collaboration from Department Directors and Medical Staff Leaders and members. + Attends Medical Staff Quality of Care Committees and presents accurate and timely data to medical staff, hospital clinical staff, and the Board of Directors. + Consults with clinical directors in regard to improvement of clinical systems and outcomes. + Assist in the training of directors and employees in the Continuous Quality Improvement process, & will assist directors in complying with state, federal, and accreditation standards. + Supervises the Infection Control specialist, as well as the QI Data Analyst. + Utilizes a variety of technical platforms including the District’s integrated information system, and external systems. + Assimilates data for QI reports to Medical Staff Subcommittees, the Quality of Care Committee, the Medical Executive Committee and the Board of Directors. + Assists in the reappointment of medical staff by providing summary of occurrences and what the outcomes of these occurrences were to the Medical Staff Coordinator. + Provides information to the CNO of situations that may result in risk management/legal issues. District Responsibility: + Demonstrates performance consistent with the mission, vision and values of the organization. + Has an extensive understanding of performance improvement, risk management and infection control. + Strives for professional development. Position Duties/Responsibility: + Resolves patient and/of family complaints in a nonjudgmental & compassionate manner, logs this information and the response from the department director where the complaint occurred. Presents data to the Quality of Care Committee and Board of Directors quarterly. + Reviews medical records with an understanding of medical and medico-legal issues. + Pulls data from charts to identify deviations from normal course of events in chart reviewing. + Logs and routes BETA Healthcare Group Quality Review Reports with all necessary information. Presents data that is aggregated from these reports within quarterly reports. + Accesses computer systems, enters and retrieves data, prints reports as needed. + Accesses Internet for + CDC Infection Control patient/employee information + The Joint Commission - Core Measures (COPE on Quadramed website) + Lumetra Collaborative and Regional information + Current practices in the Medical Field to present to Medical Staff Subcommittees + Create Focus Studies in MAXSystem with criteria fields to be populated for medical staff studies that are printed out and reported at medical staff committee meetings and to the Board of Directors. + Shares the responsibility of transmitting reportable diseases to Public Health Department using the CMR forms following timelines stated on CMR for each infectious disease. + Maintains & provides statistical data quarterly for risk management summary. + Will use various computer systems including; MAXSystem, Affinity, COPE system in Quadramed, QS Module, Microsoft Word, Outlook, & Tiny Term. Essential Functions: + The ability to maintain California Nursing license and any certification required. + The ability to have fine motor skills for computer usage including keyboarding. + The ability to review medical records. + The ability to sit for prolonged periods of time + The ability to communicate effectively both verbally and in writing + The ability to multitask + The ability to have positive interactions with co-workers, physicians or any member of the public. Position Qualifications: + Education: The Director of QI, RM, and IC is a Registered Nurse with a Bachelors Degree in Nursing. Advanced courses in Quality and Infection Control required. + Experience: Minimum of 5 years of varied clinical experience in a hospital experience. + Previous Leadership or Management experience. + Certif cations : CPHQ, CPHRM desired, but may obtain while working. + Skills/Ability: Excellent verbal and writing skills required. Exhibits the ability to organize multiple assignments & follow through with accuracy. Exercises good judgment under stress. + Demonstrates maturity, initiative, emotional stability, tact and poise. + Ability to handle multiple tasks with interruptions, works independently, follows instructions and maintains a high level of professional conduct. + LVMC reserves the right to modify the minimum requirements depending on the needs of the organization.