Administrative Quality & Compliance Director

Administrative Quality & Compliance Director

This position is responsible for all quality, compliance, risk management, patient safety, and patient experience activities within the hospital. It has primary responsibility for interfacing with the medical staff in matters pertaining to the above, and for managing the relationship with the corporate departments responsible for these functions at the system level.

• Develops and implements strategy relating to matters of quality, outcomes and experience, and for identifying and mitigating risks to the patient and/or staff. Creates and manages major elements of the Strategic A3s relating to Right Care and Patient Experience.
• Oversees all activities relating to complying with the requirements for hospital accreditation and licensure. Interfaces directly with JCAHO, the Tennessee Department of Health, and CMS as necessary.
• Oversees the hospital’s benchmarking programs including NPIC, CWISH, Solutions for Patient Safety and Vermont-Oxford. Is the hospital’s point of contact and manages the hospital’s engagement with Leapfrog, Premier, and Quest.
• Oversees the hospital’s response to, and resolution of grievances filed in the public domain.
• Administers the hospital’s adverse incident process. Oversees the investigation and evaluation of incidents, including the taking of corrective actions as needed. Identifies trends and other factors that may influence policy development.
• Oversees the discovery process in cases with the potential for claims against the hospital. Is involved in all aspects including evaluation and assessment, the consideration of defense strategies, and the recommending of settlements or other actions.
• Designs programs and oversees the orientation and education of staff in matters of quality, regulatory compliance, patient safety, and patient experience.
• Is the primary liaison with the medical staff in matters of quality, regulatory compliance, investigation of claims and actions, and patient experience. Is the hospital’s representative to the Peer Review, Perinatal Quality and Pediatric Quality Committees.
• Assists the medical staff office in matters relating to credentialing, the delineation of privileges, the medical staff bylaws and rules and regulations, and the disciplinary process.
• Is the primary interface with the corporate departments responsible for quality, compliance, risk management, patient safety and patient experience at the system level.
• Evaluates the results of the patient satisfaction survey, and prepares plans to improve the hospital’s performance.
• Participates in community health activities including mortality review, planning for events impacting the health status of the citizenry, and in the adoption and administration of regulations affecting the hospital.
• Prepares and oversees the budget for the assigned areas of responsibility. Recommends programs and expenditures that can influence outcomes, experience, and/or the mitigation of risk.
• Develops and administers policy relating to quality, compliance, risk management, patient safety and patient experience.

• Five (5) years of clinical experience as a registered nurse or healthcare management with previous experience in Quality, Risk and/or Compliance

• 5 years experience in quality, risk or compliance; baccalaureate, associate or diploma degree in a health-related field, nursing preferred;
  Certified Professional in Healthcare Risk Management (CPHRM)

• Completion of a baccalaureate, associate or diploma degree in health-related field

• Baccalaureate degree - Nursing preferred

• Knowledge of licensure and accrediting requirements; ability to communicate and work effectively with medical staff, department heads and administration; excellent organizational skills and problem solving abilities

• Registered Nurse