Director of Quality/Risk Management
Description

Job Summary:


Responsible for the development, implementation, integration and coordination of organization wide performance improvement, infection control, and clinical risk management activities. Assumes a leadership role in accreditation and licensure activities. Works collaboratively with Administration, Medical Staff, Department Managers, and staff in performing duties.


Responsibilities:

  • Develops, maintains, monitors and evaluates the quality improvement program
  • Integrates and coordinates quality activities throughout
  • Investigates events identified through the incident reporting system
  • Promptly investigates all compliance matters reported to determine their validity and potential risk
  • Coordination of internal departments and external entities to ensure compliance with company policies, and State/Federal Regulatory and Accreditation standards
  • Collects and prepares risk data/information and reports to Performance Improvement Patient Safety (PIPS) committee
  • Coordinates with nursing units and Security in regards to missing patient items/patient items left behind after departure
  • Receives, coordinates and evaluates reports and compliance of all Quality Improvement activities
  • Oversees policies and procedures that relate to quality patient care
  • Maintains organizations application and preparation for regulatory surveys
  • Coordinates projects or task forces relating to patient safety, Core Measures, Sentinel Event review or Failure Mode Effects Analysis (FMEA), as requested or needed
  • Performs other duties as assigned or required
  • Participates actively and positively affects the outcome of customer service activities
  • Demonstrates and maintains thorough knowledge of Federal, State, Local Laws and CMS/JCAH accreditation standards
  • Understands and actively participates in the hospital-wide Quality Improvement Process using the Plan/Do/Check/Act (PDCA) process
  • Is able to define performance improvement and verbalize at least one departmental or hospital-wide improvement initiative that has occurred in the last 12 months
  • Follows standard precautions and transmission-based precautions as demonstrated by consistent use of appropriate personal protective equipment
  • Uses proper body technique at all times. Seeks assistance when necessary to move heavy objects or to transport/transfer a patient


Requirements

Education and Experience:

  • Degree in Nursing or Health related field
  • Bachelors or Masters Degree in Nursing, Health Administration, Business or related field preferred
  • Active RN license or licensed in related field in healthcare
  • Minimum of one (1) – three (3) years of Management/Supervisory experience in Healthcare Performance Improvement.
  • Minimum of one (1) year experience in Healthcare Risk Management preferred
  • Proficiency in Word Processing, Spreadsheets and Database
  • Must possess strong written and verbal communication skills
  • BLS upon hire and maintain current

Required Skills/Abilities:

  • Excellent analytical and writing skills
  • Strong computer skills to include Microsoft Word, Excel, PowerPoint, and database products
  • Must be highly motivated and willing to assume additional jobs and duties as needed
  • Must be able to handle stress of working efficiently with frequent interruptions and distractions
  • Hours must be flexible to accommodate for needs during Accreditation surveys or other unscheduled events
  • Must be able to prioritize tasks and adhere to strict deadlines
  • Possess knowledge of Joint Commission Standards, Core Measures and federal and state regulations

Physical Requirements:

  • Sitting 3-6 hours a day
  • Wrist deviation (side to side and up and down) 3-6 hours a day
  • Occasionally lift up to 50 pounds
  • Occasionally be exposed to hazardous chemicals or infections