Job Summary

Quality Management Director: Responsible for planning and implementing the performance improvement program to meet the needs of the hospital. Provides education to medical staff, hospital staff, and Governing Bodies. Facilitates performance improvement activities and Quality Council activities throughout the hospital. Acts as a resource person to the administrative team, department managers, and medical staff. Assists department managers with preparation for medical staff committees. Oversight responsibility for all regulatory body surveys, i.e., the accrediting organization, State Licensing Review, CMS Validation surveys. Maintains oversight responsibility for all performance improvement activities conducted throughout the hospital.

Risk Manager: Responsible for clinical identification, risk evaluation, and coordination of corrective action implementation related to risk issues. Provides intervention and education related to risk management issues to promote safe work practices and quality care and services in an environment that is beneficial to the safety, health, and wellbeing of all patients, visitors, and hospital staff. Coordinates risk programs with all hospital departments, administration, and legal counsel. Reports real and potential risk situations to the Governing Body, medical staff, administration, hospital departments, and committees, as appropriate. Responsible for establishing and monitoring methods to avoid, eliminate and/or reduce risk situations associated with the provision of patient care and services.

Demonstrates Competency in the Following Areas

QUALITY MANAGEMENT DIRECTOR RESPONSIBILITIES:

• Oversees hospital regulatory compliance; serves as a resource on Quality for all staff and departments.
• Serves as the committee chair for the Quality Council; QMS Management.
• Demonstrates effectiveness in planning and implementing the performance improvement program to meet the needs of the hospital.
• Active in educating leadership and staff on quality initiatives and compliance measures.
• Demonstrates effective organizational skills through ongoing interaction with clinical chairpersons, nurse managers, ancillary department managers, administrative team, and Governing Body to facilitate the hospital-wide PI program.
• Demonstrates knowledge of current methodology and practices. Maintains awareness of changes in the regulations and requirements by accrediting bodies.
• Working closely with all department leaders to meet the needs of the department as it applies to regulatory and hospital compliance.

RISK MANAGER RESPONSIBILITIES:

• Knowledge of basic components of risk management, including potentially compensable events, risk investigation, reporting and claims management.
• Ability to perform medical record review for the purpose of identification of real or potential risk and the monitoring of documentation practices.
• Ability to prepare risk identification reports for submission to the legal counsel and the organizational risk carrier.
• Ability to prepare risk identification and grievance reports in summary format, for presentation to hospital administration, the medical staff and the Governing Body.
• Refers to information gathered from risk identification reporting to the appropriate department manager/administrative staff member and/or hospital mechanism for analysis and corrective action to eliminate or reduce risk. Leads and promotes patient safety.
• Leads and mentors others in root cause analysis (RCA), healthcare failure mode and effects analysis (FMEA) and hazard vulnerability analysis (HVA) teams.

GENERAL RESPONSIBILITIES:

• Demonstrates an ability to be flexible, organized, and function under stressful situations.
• Documentation meets current standards and policies.
• Performs management activities including interviewing, hiring, evaluating, and firing.
• Consistently demonstrates a professional, self-directed, mature, disciplined, and tactful approach to department responsibilities. Listens and communicates effectively.
• Communicates appropriately and clearly to physicians, staff, Nurse Executive, and administrative team.
• Assists with the coordination of performance improvement and continuous quality improvement activities for Quality Management, Risk Management and the Clinical Education Department.
• Consults other departments as appropriate to provide and to collaborate in patient care and performance improvement activities.
• Performs competency evaluations of staff members in the individual departments; Quality Management, Risk Management, and Clinical Education.
• Maintains a good working relationship both within the department and with other departments.
• Practices good guest relations with patients, visitors, physicians, and staff, assists as needed.
• Treats patients and their families with respect and dignity. Identifies and addresses psychosocial, cultural, ethnic, and religious/spiritual needs of patients and their families.

Regulatory Requirements:

• Bachelor’s Degree in Health Services Administration preferred.
• Registered Nurse preferred
• CPHQ certification is preferable.
• Two (2) or more years of experience in Quality Management.
• Two (2) or more years of previous experience in risk management, legal or insurance-related field.