Position Summary:
The Director of Quality, Risk Management and Patient Safety is a key leadership position that works under the guidance of the Senior Director of Patient Care Services/CNO. Areas of oversight, monitoring, and reporting include Clinical Quality, Patient Experience, Risk Management, Patient Safety, Regulatory Compliance, Infection Prevention, and Employee Health programs. The incumbent collaborates extensively with Executives, Board Members, Medical Staff, and Organizational Leadership to promote a culture of accountability and continuous improvement.
Work includes: developing, implementing, and evaluating the Performance Improvement plan; supervising the Corporation’s culture of safety and event management system; assuring timely investigation and resolution of complaints and grievances; managing organizational compliance with all state, federal, Medicare Conditions of Participation (CoP) regulations, and The Joint Commission standards for Critical Access Hospitals (CAHs); integrating quality, safety, and regulatory compliance into the policies, procedures, and practices that affect the organization’s operations and strategic business plan initiatives.
Primary Duties and Responsibilities:
1) Oversees the Corporation’s Quality Assurance and Performance Improvement plan to maintain safe patient care and enhance quality outcomes.
2) Maintains awareness of evolving practice standards and stays informed of emerging methodologies, tools, and approaches through active participation in State and National organizations and workgroups. Makes recommendations and changes in the Corporation’s Clinical Quality, Patient Experience, Risk Management, Patient Safety, and Regulatory Compliance programs as appropriate.
3) Works with organizational leadership to ensure a positive patient experience by working to address patient concerns and ensuring timely resolution of complaints and grievances in alignment with the Corporation’s Mission, Vision, and Values and in accordance with regulatory compliance requirements.
4) Collaborates with the Medical Staff and organizational leadership to enhance safe, quality patient care by supporting the Corporation’s peer review program and ongoing and focused practitioner credentialing and evaluation.
5) Monitors the event management system to ensure timely reporting, investigation, and closure of incidents. Promotes a culture of safety by encouraging reporting and by tracking, trending, analyzing, and communicating event management data with Organizational Leaders.
6) Ensures Root Cause Analyses (RCA) and Failure Mode Effects Analyses (FMEA) are performed in accordance with The Joint Commission standards and supervises implementation of associated action plans to prevent future harm.
7) Mitigates organizational risk by interfacing with the liability insurance carrier and assisting in the management of claims; conducting and overseeing internal audits/tracers; providing guidance on regulatory and accreditation standards that necessitate policy, practice, form, contract, etc. changes; seeking external compliance consultation and/or legal counsel when necessary.
8) Serves as the Corporation’s liaison to The Joint Commission by functioning as a subject matter expert to coordinate survey readiness activities, facilitating post-survey corrective action planning, and monitoring corrective action plan follow through.
9) Supports the Corporation’s Emergency Management Program to ensure compliance with state, federal, and The Joint Commission requirements, including the satisfactory completion of ongoing and annual emergency preparedness activities.
10) Directs the Corporation’s Infection Control and Employee Health Programs, including training, surveilling, and reporting infection/injury rates and trends, and implementing prevention strategies.
11) Administers quality and compliance education programs by identifying training needs, tracking participation, training the trainers, and facilitating education as appropriate to ensure regulatory compliance and best practices in quality, safety, patient experience, infection control, and emergency preparedness.
12) Keeps Executive Leadership informed on matters affecting quality, patient safety, risk management, regulatory compliance, and organizational well-being by communicating in a timely manner and seeking guidance and direction using the proper chain of command.
Qualifications:
Education:
- Bachelor’s degree in nursing or healthcare-related field required.
- Master’s degree in healthcare-related field strongly preferred.
- Certification in Quality (CPHQ, HCQM, or CPQPS), Risk Management (CPHRM), or Patient Safety (CPPS) required or obtained within 18 months of hire.
Experience:
- At least five (5) years of experience in quality, risk or safety program management.
- The ideal candidate will have progressive management experience and an ability to lead teams.
- Capable of directing quality assurance, performance improvement, and regulatory compliance initiatives.
Skills and Abilities:
1) Knowledge of quality management methods, tools, and techniques and ability to create and support an environment that meets the quality and strategic goals of the Corporation.
2) Knowledge of accreditation and regulatory requirements for acute and ambulatory care services (e.g. state, federal, local regulations; The Joint Commission, etc.)
3) Knowledge and experience in using lean management principles to enhance performance and productivity. Lean Six Sigma and TeamSTEPPS training preferred.
4) Ability to facilitate a multidisciplinary approach to performance improvement and foster participation in all performance improvement initiatives to share and learn best practices.
5) Ability to collect and analyze key performance indicator (KPI) data and utilize information to identify trends, monitor outcomes, make recommendations, and support decision-making.
6) Ability to interpret, develop and implement effective policies, standards and procedures relating to matters under defined scope of responsibility.
7) Ability to manage collaboratively and coach others to achieve optimal performance; delegate effectively; praise/award contributions; define clear roles and responsibilities; set goals and lead initiatives; check and adjust as necessary.
8) Ability to demonstrate effective supervisory skills, including developing clear performance expectations, hiring, coaching, conflict management, evaluating, resolving performance problems, and group facilitation.
9) Skilled in facilitating and leading meetings, committees, and projects with an ability to use these venues to support organizational leadership through performance improvement initiatives.
10) Skilled in communication (oral and written), presentation style, including the ability to concisely present data to leaders, clinicians and staff at all levels of the organization.
Physical Demands and Work Environment:
- Ability to lift or carry objects weighing up to 25 pounds Able to sit, stand, walk, bend, squat, reach, and stretch frequently.
- Needs the ability to communicate effectively through reading, writing, and speaking in person or on the telephone.
- Requires periods of sitting, standing.
- Requires frequent use of computer.
- Must be able to perform the essential functions of the job with or without reasonable accommodation.
Compensation:
$114,004.80 - $186,097.60 Annually DOE
Equal Opportunity Employer
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