Director of Quality & Risk

1.

At a manager's level, demonstrates the knowledge and skills necessary to provide service/care appropriate to the age of the patients served, in accordance with Hawarden Regional Healthcare standards. Maintains a working knowledge of applicable Federal, State and local laws and regulations, the Compliance Accountability Program, Code of Ethics, and HRH policies and procedures, including all provisions of the Health Insurance Portability Act of 1996 (HIPAA). In order to ensure adherence in a manner that reflects honest, ethical and professional behavior by implementing the organizational vision, values, and mission.

2.

Plans for and implements change, problem solving skills, delegations skills, conflict resolution skills, verbal and written communication skills.

3.

Promotes professional growth of self and staff. 

-           Utilizes coaching and counseling sessions.

-           Demonstrates organization and time management.

4.

Demonstrates knowledge of emergency plan and participates in disaster drills.

5.

Coordination of the hospital Quality programs.

1. Chairs the monthly hospital Quality meeting.
2. Prepares meeting minutes, and summary reports for the Board of Trustees.
3. Serves as resource person for department heads and other staff involved in Quality processes.
4. Conducts other audits and process improvement activities.

6.

Develops processes for selecting and coordinating performance improvement teams and projects; incorporates CQI philosophy, methods and tools into the process.

7.

Educates and guides HRH medical staff in the use of continuous quality improvement tools.

8.

Functions as a liaison to support multidisciplinary process improvement teams. Provides summarized reports regarding performance improvement events and activities to the Board, Quality Committee, Hospital Administration, Medical Staff and appropriate committees on a regular basis.

9.

Ensures compliance with all regulatory and accrediting bodies for quality outcomes tracking/reporting, performance improvement, patient safety, risk management, infection control, compliance, clinical documentation, and medical staff credentialing and reappointment.

10.

Directs the development and implementation of systems, policies, and procedures for the identification, collection, and analysis of performance measurement data. Develops and oversees a contemporary, efficient system of quality and safety measurement with timely and effective reporting to regulatory agencies, and to other internal and external audiences.

11.

Assists the Medical Staff Leadership with quality related issues. Strives to increase and maintain medical staff satisfaction with HRH services. Orients physicians, staff and peers to the research process and/or quality improvement.

12.

Identifies needs and implements education of organizational staff and physicians leading to practice improvement and clinical outcome improvement.

13.

Identifies trends in patient satisfaction and helps to identify solutions & informs staff, administration and the board.

14.

Functions as a team member in the patient complaint resolution process by consulting with the administrator and directors.

15.

Serves as the in-house resource expert on accreditation standards.  Coordinates overall accreditation processes and regulatory programs.

16.

Monitors state and regulatory websites.  Contacts regulatory agencies and other governing entities when clarification is needed and monitors the development of new/revised regulatory standards.

17.

Interprets applicable regulatory standards, recognizes and communicates issues/occurrences to the appropriate parties, and assists in identifying a resolution in order to meet standards.

18.

Provides education on accreditation requirements and state and federal regulatory compliance to all levels of the organization.

19.

Assesses compliance to Conditions of Participation standards with recommendations for change.  Evaluates effectiveness of monitoring system annually.

20.

Organizes and periodically performs patient tracers and conducts other audits to ensure compliance and state of readiness.

21.

Maintains risk management program in coordination with the Administrator.

22.

Provides oversight to the monitoring and evaluation of departmental risk identification, claim management, and loss control activities. Coordinates follow up of actual/potential adverse occurrences. 

23.

Develops, coordinates and/or presents education and communication programs for clinical and non-clinical staff related to patient safety and risk management Collaborates with departments/services to identify relevant patient safety and risk management activities and processes between and across departments.

24.

Develops and/or gives input to organizational policies and procedures on loss control and patient safety.  Incorporates Insurance/Risk Management recommendations when applicable.

25.

Participates in corporate risk management education seminars, task forces and improvement activities when the opportunity presents itself and presents and/or reports risk management issues, outcomes and recommendations to administration and the board.

26.

Investigates patient safety issues within the facility.  Implements and facilitates root cause analysis when appropriate.  Recommends and facilitates change within the organization to improve patient safety based on identified risks; ensures organizational compliance with the requirements for identifying, reporting and analyzing “sentinel events”.

27.

Recognizes and communicates issues/occurrences utilizing established lines of authority, and assists in identifying ways to resolve variances or unacceptable outcomes.

28.

Must have a general working knowledge of computers and department specific software (i.e. Healthstream, internet, etc.)

29.

Actively participates in departmental meetings, committees, conferences, and in services. Is knowledgeable of and complies with Safety and Infection Control Policies & Procedures. Participates in Continuous Quality Improvement activities as requested. Keeps up to date on new procedures and research. Maintains confidentiality of information pertaining to clients, physicians, employees and HRH business.

30.

Completes all mandatory training such as Healthstream, The Patient Experience, Safe Choices, Crucial Conversations and any other training as designated by Administration.

31.

Performs other duties and responsibilities as assigned.