Director of Quality - Risk Management - Patient Safety

Director of Quality
- Risk Management
- Patient Safety

Job Category: Management

Requisition Number: DIREC
002508

• Full-Time
• On-site

Showing 1 location

• Pay or shift range: $ USD to $ USD The estimated range is the budgeted amount for this position. Final offers are based on various factors, including skill set, experience, location, qualifications and other job-related reasons.

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 work groups. 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…