The Quality/Risk Director is responsible for an environment and culture that enables the hospital to fulfill its mission by meeting or exceeding goals, conveying the mission to all staff, facilitating staff accountability for performance, and motivating staff to improve performance.
This position manages, directs, and plans all aspects of Quality and Risk Management. The Director is responsible for hospital-wide quality management program and works with hospital administration, departments, and the medical staff to monitor and evaluate the quality of delivery of patient care services within the hospital. They will have access to all medical records for the hospital; will ensure proper compliance with regulatory agencies, accrediting bodies, and Home Office and hospital policies and procedures; and will work to develop, implement, and maintain quality assessment and improvement programs within the hospital.
RESPONSIBILITIES AND TASKS
Assesses compliance with federal, state, and industry regulatory and accreditation standards.
o Facilitates processes to remediate and/or maintain compliance.
o Provides organizational education related to the regulations and standards.
o Compiles data in usable formats for analysis against appropriate benchmarks, using current statistical tools and techniques in an effort to identify improvement opportunities.
o Prepares and submits timely, statistically correct, complete reports of risk management and quality information to the appropriate hospital, regional, corporate, or external agency.
o Successfully completes annual skills competency as determined by the hospital based on new responsibilities, specialized equipment, high risk/problem prone/or low volume procedures including emergency response techniques. All assigned training must be completed by required completion date.
Coordinates local/state/federal/accreditation surveys and associated action plans and assessments.
o Submits corrective action plans and assessments (i.e., TJC PPR) to regulatory and accrediting bodies within required timeframe.
o Oversees oversight of corrective action plan through ongoing monitoring.
o Maintains appropriate records and documentation of Quality Council, MEC, and Governing Body activities including minutes, supporting data, logs, and all related documents in accordance with state and federal law.
Facilitates committees, teams, and plan documentation for performance improvement.
o Ensures that the following PI teams are in place: falls PI committee, FMEA, and others per hospital priorities.
o Mentors others for the leader and facilitator role in the performance improvement process.
o Encourages others to serve as PI team leaders and facilitators.
o Ensures updates and maintenance of hospital plans is completed (for example Plan for the Provision of Care/Scope of Services, Leadership, Information Management, Utilization Review, Infection Control, Performance Improvement and Patient Safety).
Manages implementation of hospital policies and applicable corporate (e.g., Compliance) policies.
o Coordinates the review, revision, development, approval, and implementation of hospital specific policies.
o Coordinates the implementation of corporate policies applicable to the hospital.
o Acts as an organizational liaison with the CEO and Corporate Compliance to ensure implementation of the Standards of Business Conduct and all applicable compliance policies.
Collaborates with other departments to coordinate care and resolve customer concerns or complaints.
o Oversees complaint process including complaint investigation; verbal and written complaint follow-up; corrective action planning; and maintenance of complaint log.
o Resolves issues promptly as outlined in the Corporate Patient Complaint/Grievance Policy.
o Ensures verbal/written follow-up occurs within required timeframe and in accord with Corporate Risk Management policy.
Coordinates all RCA (root cause analysis) and sentinel event report development and submission.
o Submits reports to required local, state, federal and accreditation agencies related to sentinel events and mortality as required by local/state/federal jurisdiction and/or accreditation agencies.
Shares Patient Satisfaction data with leadership/staff monthly (min.) and coordinates improvement.
o Identifies opportunities for improvement and coordinates the organizational efforts to improve patient satisfaction.
Oversees risk management activities including completion of reports/claims/plans.
o Completes incident reports, notice of potential claims, corrective action planning and incident reporting to Corporate Risk Manager.
o Completes monthly online reporting to Corporate Risk Management within required timeframe.
Uses a variety of applications to perform technical analyses and planning.
o Identifies improvement opportunities, generates reports, research issues, identifies resources, and accesses external databases.
o Maintains familiarity with company applications including but not limited to PatCom, UDS, ORYX, and Press Ganey
Organizes, plans, and manages time effectively to complete assignments.
Meets position requirements and performs essential functions.
License or Certification:
Licensed or certified according to individual state requirement.
- Bachelor's degree in healthcare or related field preferred.
- Quality and/or Risk Management experience including primary responsibility for performance improvement activities, regulatory compliance, conflict resolution, leadership, and risk management activities.
- Licensed or certified according to individual state requirement.