Director of Quality and Risk Management

Director of Quality and Risk Management

Job Description

Title: Director of Quality and Risk Management

Department: Nursing

Reports To: Chief Nursing Officer

POSITION SUMMARY:

Reporting to the Chief Nursing Officer (CNO), the Director of Quality and Risk Management coordinates activities of personnel engaged in all aspects of quality in accordance with the organization’s policies and procedures. The Director will be responsible for reviewing concerns related to risk for the hospital and clinics. The Director will oversee and lead the Patient Experience Committee.

PRINCIPAL DUTIES AND RESPONSIBILITES:

• Monitors the implementation of the quality program. Maintains an effective, ongoing, systematic hospital-wide, patient-oriented quality assurance plan. Ensures the plan is designed to measure, assess the quality of patient care and organizational functions as evidenced by patient health outcomes or improvement in processes, or both.
• Develops an annual Quality Assurance Process Improvement (QAPI) plan that evaluates the effectiveness of the program and plans for coming year.
• Compiles monthly and/or quarterly reports on hospital core measures and improvement plan for CNO and CEO.
• Meets monthly with Quality Committee.
• Meets as needed with department managers to develop meaningful and specific quality indicators.
• Notifies CEO, CNO, and department managers of changes in Conditions of Participation (COPs) pertaining to hospital.
• Compiles monthly readmission report to be shared at Medical Staff meeting.
• Updates WCMH Quality dashboard monthly. Dashboard is shared at Board of Directors meeting, Medical Staff meeting, Allied Health meeting, and department managers meeting.
• Ensures that employees and leadership are knowledgeable about and comply with pertinent federal and state standards.
• Ensures that measurements of quality of care, which are outcome or process based, are specific to the organization, and to identified needs and expectations of the patients and staff.
• Develops, coordinates, and participates in a multifaceted educational and training program that focuses on the elements of quality.

Non-Direct Patient Care

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• Professional growth and accountability
• Demonstrates ethical behavior
• Accepts responsibility for own actions and recognizes limitations and need for assistance.
• Participates in in-service programs

Leadership/Relationship to others/Communication Skills

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• Strives for excellence
• Communicates with health team members in a tactful and helpful manner
• Develops and maintains a good working relationship among health care team members and leaders

Other Behavioral Factors

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• Assists in overall operation of departments

Professional Requirements

• Adheres to dress code, appearance is neat and clean.
• Completes annual education requirements.
• Maintains regulatory requirements, including all state, and federal regulations.
• Maintains and ensures patient confidentiality at all times.
• Reports to work on time and as scheduled.
• Wears identification while on duty.
• Attends annual review and performs departmental in-services.
• Works at maintaining a good rapport and a cooperative working relationship with physicians, departments and staff.
• Represents the organization in a positive and professional manner.
• Attends and/or leads committee meetings, as appropriate.
• Ensures compliance with policies and procedures regarding department operations, fire, safety, infection control and emergency management.
• Complies with all organizational polices regarding ethical business practices.
• Communicates the mission, ethics and goals of the hospital, as well as the focus statement of the department.

EDUCATIONAL/EXPERIENCE REQUIREMENTS:

• Graduate of an accredited school of nursing.
• Current license by this state as a registered nurse.
• Bachelor’s Degree in healthcare management or nursing is preferred.
• Minimum of five (5) years prior experience in healthcare management or nursing.
• Experience in medical legal issues in a health care environment.
• Knowledge of quality and compliance issues, regulations, and financial and administrative auditing techniques.

BUSINESS AND COMMUNICATION SKILLS:

• Must be able to speak, read and write the English language.
• Must possess the ability to read, analyze and interpret contracts, reports, technical procedures, governmental regulations, group purchasing documentation; to compile and write reports and business correspondence.
• Must be able to effectively present information and respond to questions from groups of managers, clients, customers, physicians and the general public.

REASONING ABILITY:

• Ability to define problems, collect data, establish facts, draw vivid conclusions and create or assist with the creation of solutions to resolve issues.

COMPUTER/OFFICE EQUIPMENT SKILLS:

• Must have basic knowledge of Microsoft Word, Excel, be able to negotiate e-mail, use the internet to search for articles and information, 10 key calculator, copy/scan/fax machine and use/ learn CPSI system reporting functions to compile computer based reports.

PHYSICAL ABILITES /WORKING CONDITIONS:

Must be able to:

• Sit (be able to tolerate long periods of sitting), bend or lift and move intermittently during working hours.
• Deal with frequent interruptions.
• Deal fairly with co-workers in related issues and work harmoniously with professional and nonprofessional personnel.
• Be aware that may be subjected/exposed to infectious diseases.
• Be willing to work hours other than regular shift/weekdays if needed.
• Attend and participate in continuing educational programs for work related issues.
• Possess ability to make independent decisions when circumstances warrant action.
• Must be CPR certified.
• Understand and carry out written and oral instruction.
• Possess site/hearing senses, or use prosthetics that will enable these senses to function adequately so requirements can be met.

ACKNOWLEDGEMENT

I have read this job description and fully understand the requirements set forth therein. I hereby accept the position of Director of Quality and Risk Management and agree to abide by the requirements set forth and will perform all duties and responsibilities to the best of my ability. I understand that as a result of my employment, I may be exposed to highly contagious communicable diseases and viruses.

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Signature: Director of Quality and Risk Management Date:

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Signature: Chief Executive Officer Date:

Job Type: Full-time

Pay: $30.00 - $45.00 per hour

Benefits:

• Dental insurance
• Employee discount
• Flexible schedule
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Retirement plan
• Vision insurance

Schedule:

• Monday to Friday

Experience:

• Quality management: 1 year (Required)

License/Certification:

• RN LICENSE (Required)

Work Location: In person

Salary : $30 - $45