Director, Quality & Risk

We are seeking a professional to fill the position of Director, Quality & Risk. The ideal candidate will d irect the activities and resources for the Quality Management department to achieve departmental and organizational objectives

ESSENTIAL FUNCTIONS

• Develops and implements departmental goals, plans, and standards consistent with the clinical, administrative, legal, and ethical requirements / objectives of the organization.
• Directs and evaluates departmental operations, including patient care delivery, information technologies, service level determination, and complaint management, to achieve performance and quality control objectives.
• Plans and monitors staffing activities, including hiring, orienting, evaluating, disciplinary actions, and continuing education initiatives.
• Prepares, monitors, and evaluates departmental budgets, and ensures that the department operates incompliance with allocated funding. Coordinates and directs internal / external audits.
• Creates and fosters an environment that encourages professional growth.
• Integrates evidence-based practices into operations and clinical protocols.
• Provides prompt notification to appropriate parties upon receipt of claim or lawsuit. Assist HSC Risk, leadership and external counsel in defense of the claims as instructed.
• Provides leadership, counsel, and support in areas of Risk Management.
• Escalates significant risk issues with urgency.
• Collaborates with site patient safety / quality improvement and patient experience leadership to respond to patient grievances. Uses decision making ability to analyze and recommend disposition strategies. Oversee and direct occurrence reporting process for site. Ensures timely data entry of reports received. Completes necessary trend analysis of occurrence reports.
• Collects data for risk exposures and provides feedback to the involved departments. Ensure identified risk management strategies are undertaken by affected areas.
• Develops a safety culture where reporting is encouraged and use of SIM reporting system is monitored, with interventions to address issues as needed.
• Provide in-service education on risk management topics, both standard basic education and complex focused topics as needed and / or requested.
• Provide statistical analysis for review by appropriate committees as requested.
• Create and implement new programs to foster a culture of safety and safe environment for patients, visitors, and staff.
• Coordinate and oversee the development of comprehensive accreditation improvement initiatives to establish compliance with regulatory agencies.
• Coordinate and ensure the implementation of organization-wide regulatory compliance activities with The Joint Commission, CMS, and other regulatory agencies.
• Facilitates the development of ongoing readiness action plans, assessments, and educational activities as appropriate.
• Utilizing the standards and regulations from CMS and TJC, oversees concurrent monitors to determine if staff knowledge and clinical practice meet appropriate standards.
• Coordinates risk reduction activity in the physical environment as specified within each Environment of Care(EOC) Management Plan.
• Facilitate the organizations Regulatory Committee.
• Participates in interdisciplinary collaboration to measure and assess processes and outcomes, and proactively identify potential solutions with the multidisciplinary team and appropriate service line leaders and directors.

LEADERSHIP CAPABILITIES

Educational Requirements

Required Skills

Minimum Work Experience