Registered Nurse - Director of Quality
At Mimbres Memorial Hospital and Nursing Home located in beautiful Deming, New Mexico, we take caring for people very personally. In fact, our goal is to treat every person who turns to us for care like we would a family member. For fun, adventure and discovery, there is no place like Deming, New Mexico! Located in the heart of the historic Old West, there are plenty of things to see and do around Deming!
We offer an array of medical, dental, and vision packages as well as several add-on perks to make your benefits package truly customizable to you and your family needs. Some of our unique benefits we offer include:
Tuition Reimbursement Programs
Paid Time Off
401k
Identity Theft Protection
Pet Insurance
Job Summary:
Facilitates alignment between improvement initiatives and the organization’s strategic plan; directs the day-to-day execution of the strategies and tactics necessary to successfully improve the outcomes and results of the organization.
Responsible for maintaining the facilities system-wide Quality program; to include data collection, aggregating and analyzing data, maintaining policies and procedures, and reporting to administrators, Medical Staff, and the Board.
Works closely with Clinical and Non-Clinical teams for improvement on key performance indicators, designs processes for new initiatives, services and other targets identified by Hospital leadership.
Serves as an internal consultant to administration, staff, and physicians in the areas of regulatory, process improvement, performance monitoring, and statistical analysis.
Focuses on better healthcare value and quality, including the improvement of clinical outcomes, patient experience, patient safety, costs, revenue, productivity, efficiency, employee and physician satisfaction, and process reliability.
Coordinate, manage and report Core Measures, ACO/MIPS/MACRA and meaningful use measures and other quality metrics as assigned.
Collects and reports HCAHPS data for the facility.
Organize all Quality Management meetings, maintain minutes and make recommendations to the committee based on best practice and current regulatory standards.
Conduct internal audits and risk analysis as determined by the Quality Committee.
Participate / Coordinate in nursing and physician peer review processes and chart reviews, as necessary.
Mange and support physician peer review processes by ensuring the collection and analysis of data for provider FPPE/OPPE, scorecards, quality metrics, etc.
Analyzes all assigned areas for opportunities of improvement and makes applicable recommendations for process, system, procedure, and operational changes to improve healthcare value and quality ie: Core Measures, Hospital Acquired Conditions, etc.
Assists in the establishment of operational performance measurements and the monitoring of trends in key performance indicators to evaluate effectiveness, reliability, efficiency, etc. using available information systems data. Where other data is necessary but not readily available, will design and implement appropriate data collection. Uses data from appropriate external sources, including comparative databases.
Manages performance improvement projects, flow and alignment to assure milestones and key performance indicators are met within defined parameters. Documents the results of projects, and submits other documentation as requested.
Participates in the Grievance Committee and works with department leaders to resolve investigations within the incident reporting system.
Evaluate and document the effectiveness of the quality management system.
Design, coordinate and maintain various aspects of the patient safety and risk management programs for all of the Hospital and its affiliated clinics.
Review, investigate and analyze incidents for risk and adverse event identification, loss prevention and claims management purposes, including both potential and actual patient injury. Recommend interventions which will enhance the safety and well-being of patients, staff and organization at large.
Mobilize departmental or administrative support to address unresolved high-risk practices.
Qualifications:
Registered Nurse required.
3+ years experience in a hospital facility required, Quality/Risk leadership experience, preferred.
Master’s degree in nursing, healthcare administration, or a similar field of study with a strong analytical base, preferred.
CPHQ (Certified Professional in Healthcare Quality), preferred
Travel is infrequent.
Understanding Healthcare
Strong accounting knowledge and experience.
Good communicator.
Excellent in Excel (pivot tables, V-lookup’s, etc.)
Critical thinking and problem-solving abilities.
This is an exciting opportunity for a skilled director to lead a dedicated team in providing exceptional care. We offer competitive compensation packages and opportunities for professional growth. If you are passionate about making a difference in the lives of others, we encourage you to apply!
#ZR
Education
Required
Bachelors or better

Mimbres Memorial Hospital

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Registered Nurse - Director of Quality