What are the responsibilities and job description for the Director of Quality and Risk Management position at Edgerton Hospital and Health Services?
Description
With a range of services - from emergency care to diagnostic imaging, rehabilitation and surgery - we serve people of all ages in Edgerton, Milton, Janesville and the surrounding communities. Edgerton Hospital has been the center of the community's health care since 1920, and we continue to grow and evolve in response to changing medical needs.
Our Mission
Improving Health & Wellness for Longer, Healthier Lives
Our Vision
We will serve our communities with exceptional quality, innovative health services and wellness promotion.
Our Values
I CARE
Integrity. Compassion. Accountability. Respect. Excellence.
Join an organization that truly values your overall health and well-being & provides excellent work / life balance!
Our Director of Quality and Risk Management reports to the Chief Executive Officer and performs the following duties to support Edgerton Hospital :
- Oversees : Safety and Compliance Officer, Environment of Care, Employee Health Nurse and Infection Prevention.
- Provides quality improvement (QI) leadership and consultative services for the hospital and medical staff in effectively achieving regulatory accreditation and organizational compliance for QI activities.
- Serves as a working member of the Continuous Quality Improvement, Corporate Compliance, Medical Executive, Environment of Care, Patient Care Management and Accreditation Committees.
- Effectively oversees and coordinates with the Safety and Compliance Officer for hospital accreditation standards and surveys.
- Investigates incident reports, patient complaints, patient care issues and other issues as requested by management.
- Receives, reviews, analyzes and summarizes reports from various departments and minutes of committees of teams in relation to process improvement projects.
- Develops and updates the Quality Assurance Performance Improvement (QAPI) Plan, Risk Program Plan, and Annual Critical Access Hospital Review annually.
- Appropriately reports issues found during record reviews to utilization review, infection control and other departments as necessary.
- Investigates and manages all hospital liability claims keeping the Administrative Team informed of progress.
- Acts as a liaison between hospital and liability insurance carrier; in collaboration with CEO, notifies carrier of all actual and potential claims.
- Oversees and manages hospital-wide incident reporting system including an integrated patient safety program.
- Administers the medical staff peer review program including investigations for quality of patient care.
- Organizes, compiles and reports QI data for both the hospital and medical staff to identify trends, establish priorities and recommend improvement activities.
- Acts as the primary contact between the hospital and the Quality Improvement Organization (QIO).
- Evaluates and advises on the composition, agenda and goals of the Continuous Quality Improvement (CQI) Committee through which all reports on performance improvements are received and follow up action monitored and / or initiated.
- Prepares reports for the Board of Trustees : monthly for Quality, quarterly for Corporate Compliance and Environment of Care.
- Attends Board of Trustees meeting biannually to provide Quality Report.
- Plans, promotes and organizes activities related to quality and risk reduction for the hospital.
- Educates self and hospital staff on current state and federal, as well as, the latest quality and risk management techniques in health care.
- Drafts and revises policies and procedures relating to the quality and risk programs.
- Prepares and monitors the budget for the operation of the Quality and Employee Health departments.
- Surveillance of all hospital areas to detect breaks in standards of care and possible problem areas.
- Assures orientation of all employees as to the importance of quality improvement and service recovery.
- Perform the reporting of quality data for the various facility, county, state, and federal reporting requirements, to include : WHA, RWHC, CMS, and Patient Satisfaction (HCAHPS / OASCAHPS) data.
- Other duties as assigned.
Requirements