Director of Quality/Risk Management

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

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