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Director of Quality Management in Madisonville, KY at ContinueCARE Hospital at Baptist Health Madisonville

Date Posted: 3/20/2018

Job Snapshot

Job Description

Summary of essential job functions

  • Demonstrates and understands the importance of and respect for the rights, dignity and individuality of each patient in all interactions.
  • Maintain current Quality Improvement plans, policies, procedures, and programs.
  • Gather, disseminate, and document information on patient care Quality to facilitate compliance with requirements of accrediting and regulatory agencies.
  • Coordinate and integrate all Quality Improvement activities within the hospital.
  • Advise and assist medical staff and allied health care personnel in the Quality process.
  • Provide an ongoing assessment of the Quality Improvement program.
  • Conduct studies and prepare reports and correspondence for patient care evaluation studies; monitor and maintain records.
  • Keep appropriate committees informed of changes in accrediting and regulatory standards; maintain a close liaison with other hospital department heads to assure coordination, standardization, and continuity of Quality Improvement programs.
  • Provide in-services on Quality Improvement philosophy, plans, policies, procedures, and programs as needed.
  • Coordinate concurrent review studies performed within the Quality Improvement Programs and prepares resulting reports.
  • Establish and maintain tracking systems for reporting data and ensuring that the programs result in quality improvement. Report data/indicators to The Joint Commission
  • Keep current with state laws, federal laws, and regulatory agency requirements for hospitals regarding utilization and quality management.
  • Assist Administrator/CEO in developing Medical Staff Bylaws, Rules, and Regulations to assure compliance with The Joint Commission standards.
  • Collate incident reporting monthly and report results as required, and act as Hospital Risk Manager.
  • Ensure survey readiness.
  • Manage and coordinate survey preparation and ongoing compliance.
  • Ensure compliance with measures for preventing exposure to blood borne pathogens.
  • Serve as the Risk Manager for the hospital, and delegate tasks as appropriate.
  • Monitor compliance with the seven safety plans with-in the EOC Management Program.

            Corporate Compliance


The Compliance Officer for Hospital provides direction and oversight of the Hospital Compliance Program.  The Compliance Officer is responsible for identifying and assessing areas of compliance risk for the hospital; communicating the importance of the Compliance Program to executive management and hospital staff, medical staff and vendors, preparing and distributing the written Code of Conduct setting forth the ethical principles and polices which are the basis of the Compliance Program; developing and implementing education programs addressing compliance and the Code of Conduct; making the hospital staff aware of a retaliation-free internal reporting process, including an anonymous telephone reporting system; and collaborating with executive management to effectively incorporate the Compliance Program within system operations and programs and to carry out the responsibilities of the position.


  •  Adheres to all components of the Hospital Compliance Plan in performing job duties and reports any violations or suspected violations of the Plan to the Compliance Officer.
  •  Demonstrates professional conduct and complies with hospital and departmental policies and procedures.
  •  Adheres to hospital attendance policy as outlined in the Employee Handbook.
  •  Complies with measures for preventing exposure to blood borne pathogens.
  •  Participates in the Hazardous Material Program; hazards include exposure to blood and body fluids, possible communicable diseases, sharp objects and instruments, assorted chemicals and gasses as listed in the Hazardous Materials Program Manual.
  •  Complies with established Safety and Patient Safety Program practices.
  •  Performs other incidental and related duties, as required and/or assigned.
  •  Develops an understanding of responsibilities for recognizing patient abuse and follows policy for making appropriate referrals/interventions.
  •  Develops an understanding of responsibilities for participation in Performance Improvement activities and participates in such activities.
  •  Limits access to protected health information (PHI) to the information reasonably necessary to do the job, and shares such information only on a need-to-know basis for work purposes.

 (Access to verbal, written and electronic PHI for this job has been determined based on job level and job responsibility within the organization.  Computerized access to PHI for this job has been determined as described above and is controlled via user ID and password.)


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