System Director of Quality and Compliance

ESSENTIAL RESPONSIBILITIES (not intended to be an all inclusive list)

Corporate Compliance

• Leads the creation, implementation and operations of the organization’s compliance plan.
• Chairs and actively participates on the Corporate Compliance Committee ensuring that the highly dependent relationships between Corporate Compliance and Risk Management are well managed.
• Investigates and acts on matters related to compliance, in participation with legal counsel in the appropriate reporting of violations.

Risk Management

• Attends safety committee meetings on both campuses and assist in the development of action plans with the safety committee leaders.
• Identifies and develops corporate risk management policies and procedures and monitors compliance.
• Reviews and monitors for adequacy of applicable facility policies and procedures and work practices for risk reduction, mitigation, and control purposes.
• Facilitates predictive analysis of high-risk problem prone processes to identify potential failure points before an adverse events occurring.
• Oversees investigations of major adverse events and claims. Develops and maintains investigational procedures for the organization. Assists as needed in post-event investigations and system analysis for root causes.
• Partners with the Campus Directors to maintain an event reporting system and analyze data to identify and prioritize risk management efforts.
• Carries the responsibility for informing risk management consultant of reportable events.
• Acts as primary liaison to risk and claims consultants and vendors.
• Ensures the collection and analysis of data to monitor the performance of processes that involve risk or that may result in serious adverse events (e.g., medication processes, restraint use, care of residents at risk of pressure ulcers).
• Oversees the organizational risk management information system for data collection and processing information analysis, and generation of statistical trend reports for the identification and monitoring of adverse events, claims, finances, etc.
• Assures compliance with data collection and reporting requirements of governmental and accrediting agencies.
• Implements and manages programs that fulfill regulatory, legal and accreditation requirements.
• Develops systems for, and overseeing the reporting of, adverse events, near misses, and potentially hazardous conditions. Reporting responsibilities may include internal reporting, reporting to claims consultants, and reporting to governmental agencies
• Analyzes data collected on adverse events, near misses, and potentially hazardous conditions, providing feedback, and utilizing this data to facilitate systems improvements to reduce the probability of occurrence of future related events.
• Proactively advises the organization on strategies to reduce hazards and improve the overall safety of residents, visitors, and staff.
• Support quality assessment and improvement programs throughout the organization.
• Facilitates and ensures participation in educational programs in resident safety and risk management
• Creates, launches and manages the implementation of resident safety initiatives such as improvements in medication safety systems, fall prevention programs hazardous wandering and elopement prevention initiatives, and skin integrity pressure ulcer prevention programs.
• Decreases the likelihood of claims and lawsuits by requiring each organization or facility to develop a resident and family communication plan and developing a resident/family advocacy policy.
• Minimizes the risk of liability to the organization which will protect the financial, human and other tangible and intangible assets of the organization.
• Reduces the probability of events that may result in physical losses to organization and equipment (e.g., bio-medical equipment maintenance, fire prevention).
• Decreases the risk of lawsuits through effective claims management. Investigate and assist in claims resolution to minimize risk exposure.
• Collaborates with external claims and risk management organizations and participates in CCSS claims and risk management programs.
• Reports events/potential claims as needed to claim consultants in accordance with the CCIC Claims Manual.
• Monitors the effectiveness/performance of risk management and resident safety actions.

Performance monitoring data may include:

• • Resident and family satisfaction surveys to ensure needs and expectations are being met
  • Ongoing risk assessment data
  • Quality indicators (including the Centers for Medicare and Medicaid’s Nursing Home Quality Indicators)
  • Event trending data
  • Research data
  • Employee engagement and satisfaction

Corporate Quality Assurance

• Assists peers in providing data for the Quarterly Quality Committee report.
• Leads the review, revision, and development of policies and procedures.
• Coordinates networking between Oakwood and other organizations utilizing CQI concepts.
• Manages the annual mock survey process.
• Partners with managers and teams on quality audit implementation and reporting.
• Assists in providing “Quality Program” portion of general orientation.
• Facilitates project teams as requested.
• Collaborates with teams on meeting process, data collection, analysis, and communication of results (technical consultation).

Other Duties

• Designs and implements strategies and plans related to the in-care and service delivery for its residents, family members, employees and other various community constituent groups that are a part of the fabric of the organization.
• Participates in and ensures quality improvement methods and strategies are employed to continuously achieve organizational excellence and best practice quality outcomes.
• Develops and monitors department budget that supports the initiatives approved for implementation.
• Provides leadership and guidance to ensure optimal performance of those reporting to the incumbent.
• Responsible for operational oversight of functions reporting to this position.
• Augmenting the organization’s strategic plans, incumbent will develop a work (tactical) action plan to accomplish identified and approved initiatives. Included in this tactical plan is the requirement to establish measurable goals to indicate personal and organizational performance and to ensure that the plan remains on track.
• Conducts appropriate research to determine the best plan for each initiative to be implemented.
• Develops the organization infrastructure to support the respective functions to successful outcomes.
• Develops and maintain a flow of information to corporate and facility-level managers on a routine basis as determined by Board and/or Administration .
• Performs similar and related duties as assigned as a member of the organization’s leadership team.
• In a multi-campus organization will have oversight authority for campus-level risk management designee.
• Facilitates quarterly progress on the Oakwood Clinical Priorities and maintains the documentation and reporting that provides updates to the DCS and CCLT.

• Strong knowledge and understanding of the following:

• • Risk Management
  • Corporate Compliance
  • Quality improvement
  • HIPPA Compliance
  • Overall administration and operations
  • Strong analytical and problem-solving skills
• Possesses requisite communications skills to effectively represent the department in written as well as verbal context to internal and external audiences - staff, management, Board of Directors, business partnerships, attorneys, etc.
• Effectively leads and motivates staff. Proven track record of successfully leading and implementing programs and initiatives through times of significant change.
• Creative and talented in the recognition of new, workable solutions to current operations that are essential to the continued financial viability of the organization and minimize organizational liability.
• Strong attention to detail and follow-through to ensure that key elements of initiatives/problems are followed through to resolution.
• Must possess the qualities of honesty, integrity, loyalty, and mission and values-based work ethics
• Proven track record of exercising good judgment and maintaining confidentiality in dealing with all aspects of the leadership role for these functions.

Experience/Training/Education

• Must have an active RN license in the state of Wisconsin.
• Bachelor's Degree in Business Management or healthcare related field, Master's preferred.
• Minimum of 7 years experience in a leadership role in a relevant setting.
• Assisted Living and or Skilled Nursing experience preferred.